HomeMy WebLinkAboutApp-Permit-ComplianceNo. a
FEE
10-z� I COMMONWEALTH"OF MASSACHUSETTS
Board of Health, YARMOUTH HEALTH D T.
�enG�►� 1146 ROUTE 98
APPLICATION FOP, DISPO1RLy1M?MftMWJCTION PERMIT
+plication for a Permit to Construct( ) Repair/Upgrade( ) Abandon() - ❑ Complete System Individual Components
19f
Location
Owner's Name 1\0exp-c"
-C-p,,e-
Map/Parcel# 111A. 0-1 ke
Address S9 - k) cLMcwX
CW f- H txe- !N
Lot#
Telephone# �'1 3ULA - Lk Q 2
Installer's Name t
Designer's Name AV14kA
VI/ ,. VL
I.Address 3� N.t4\r, s�
Address PC),
Telephone# 1-j $ - 23 - 2-161
Telephone# c),6 ,
Type of Building �`-&-Wl A Q Lot Size lw��� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) l D gpd Calculated design flow 3 Design flow provided :?33,Sl gpd
Plan: Date O, I I O Number of sheets -Z—' Revision Date
Title
Description of Soils) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS KOLMD 1VQQl T-, 1 e a -J "
c3i Rev's O� ��w1-S f!l Loedgto F A45 W1 6#4k
The un
further
Signed
the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
system in operation until a Certificate of Compliance has been issued by the Board of Health.
No. �� � 0 ��:/C/ / Y'✓� ! � C.f Gt d LJI�f'. y' �EE � S ^"=_
COMMONWLALT14 Of MASSAC14USETTS lo --i46
Board of Health,TIW Y'1yv+V� , MA. b�
CERTIFICATE OF'COMPLIANCE 49
Description of Work: J2T51vidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (✓Upgraded ( ), Abandoned ( )
by: JQ
Q --
at 1 `i �5VW ca2yt A
has been installed in accord ce with the provisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
applicatio No. �v dated 3 `�i �� . Approved Design Flow (gpd)
Installer (61 C e t
Designer:Inspector: 1, Date:
r
The issuance of this permit shall not be construed as a guarantee t4at the system will function as designed.
No.�� / % v(/
,/ ! � � FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA•
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(--,/
epair(' Upgrade( ) Abandon( ) an individual sewage disposal system
at �j C (2-ck as described in the application for
Disposal System Construction Permit No. JV dated
Provided: Construction shall be completed within t r& yea -r -s of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 3"- q Board of Health