HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28 _
No. ? SO. YARMOUTH, MA 02664 FEE -Q
COMMONWEALTH Of MASSAC14USETTS
Board of Health, , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( )/Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
LocationL ,e �'r+
Owner's Name l - %� oL--o 1-� A R N e ,@
Map/Parcel# Ivau
Address L/,? �a A
Lot# C�
Telephone#
Installer's Name el? o c') fe
Designer's Nam I novo p /l of SG A)
Address 44 IN 1 cr,
Address C4 i✓®
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Lot Size sq. ft.
Garbage grinder'40
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) f /C — gpd Calculated design flow �� 0 Design flow provided 73 gpd
Plan: Date 15l �Z Number of sheets Revision Date
Title
Description of Soil(s).C, o dt� b fJ
Soil Evaluator Form No. a Name of Soil Evaluator "Z�? ^O1 ,4 EQ r\.) Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to ElWe the system in operation until a Certificate of Compliance has been issued by the Board of Health.
ySigned ° `(` Date 9 7
Lspecti ns .�' �D `[ G�ll�4�.�� G'�r.2�D(_�AWf3£LS (AsE I %/ ht Sk 4n
No. f� /' FEE U
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, �/G''�-, MA.
CERTIFICATE Of COMPLIANCE V
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (✓�Upgrdded ( ), Abandoned ( )
by: (� D �C.'
at L 13 u r2 :ti e %� •r f ( [/�' .o �.-� `% so d7 K4 c. trY�j
has been installed in acc rd nce with the rovisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. 'J77, dated W /%`J� . Approved Design Flow 7 gpd)
Installer
Designer: G•'. /r'// a7t! Inspector:
Date: 'r -,)<)
The issuance of this permit shall not be construed as a guarantee that th6 system will function as designed.
�� ,,,�'�
No. r�j FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, �'���� MA.
DISPOSAL SYSTEM CONSTRUCTION- PERMIT
t
Permission is hereby granted to; Construct( ) Repair(-, Upgrade ( ) Abandon ( ) an individual sewage disposal system
at L t- fes' >v -e�qy�� I 1 j c as described in the application for
Disposal System Construction Permit No. / "' 3/ 7, dated
Provided: Construction shall be completed within three years of the date of this perm' All local conditions mustbem/ee
�Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -/7- re/ ,%oard of Health Gr✓ -""�