HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 7-115; FEE
COMMONWEALTH Of MASSACHUSETTS �� �°�� �7
Board of Health, 4 , MA.
APPLICATI®N E®II DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (6
Abandon() - `+Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name Ge
Designer's NSUPMEN.J. DONLE AND ASSOCUTEN
Addressne L ave"
Address AST FALMOUTH MASSACHUSETTS 02ND
Telephone# �g _ _ L( 6- Z
Telephone#
Type of BuildingP v�c�Zs� Lot Size /&D 0 sq. ft.
wellin - o. of Bedrooms ] Garbage grinder ( )
er - Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. re i
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
10:3gpd Calculated design flow '3 S O
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided -S -ZS I gpd
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to not to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
igned - Xte -7-06P
• Inspections
COMMONWEALTH OF MASSACHUSETTS
Board of Health, (1& MA.
CERTIFICATE OF COMPLIANCE
FEE S 4Z
,W 6, � i
Description of Work: ❑ Individual Component(s) 30domplete System
The undersigned herebycertifythat the Sewage Disposal System; Constructe8 rRepaired ( ), Upgraded ( ), Abandoned ( )
by: 11W r -u o
a
at s� !?rrf `"� -/ r1 r- .-1 7a o4w)e., ram'T-
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No, lr%-, /��' Cy , dated Approved Design Flow �i'�% (gpd)
Installer _ I°'
Designer: t �7 .. G�L1 Injpector: i Dater / a f
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. d (,' / U r --t t r FEE
COMMONWEALTH MASSACHUSETTS)41
Board of Health, 1 t.� r ?116 J t , MA.
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at `� l r�ir- t _C_'�' �wmoj as described in the application for
Disposal System Construction Permit No. i� -//9 , dated .
Provided: Construction shall be completed within tbjk raf the date of this permit., All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date , l Board of Health ' `