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No. � :' , FEE
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COMMONWAW&OAN&WOUSETTS
Board of H: 1 ROUTE 28
MA.YARMOUTH, MA 02664
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ®-Complete System ❑ Individual Components
Location
U •
Owner's Name
Q „/
Map/Parcel#
Address
2 _ ►-M
Lot#
-D ®
Telephone#
CX6 �� I
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Installer's Name
N S� o d
Designer's Name
is
t
Address 9
Address
Telephone#
60(r,— -77 ,-• -
Telephone#
�Q,qr
-361
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
R
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) % gpd Calculated design flow 9jQ0 Design flow p� ovided AMP gpd
Plan: Date Zr� Number of sheets ®f13t Revision Date V 7
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS 94 A
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 agrees to not to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Naaitw�2, 11.tY� oCDoln
r Inspections 7 sgIt �
d 7V
No. Fy G/
r! �!
Board of Health, y�{Iya.��,, , �
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ® Complete System
The undersigned hereby certi that the Sewage Disposal System; Constructed ( ), Repaired (X), Upgraded ( ), Abandoned ( )
has been installed in accord n e with the provisio sof 3 0 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. dated `�%` � Approved Design Flow �d/ (gpd)
Installer G-nY�_t1r1- L.7Y\S�'i+.tXlo.� A t.7~ 2'' /Ll All 2
rr v ' .+� Q
Designer: ty `"fit,, V 4 A rL Inspector: / Date: �� 7
The issuance of this permit shall not be construed as a guarantee 1hat the system will function as designed.
No.'�5 FEE V U
19
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COMMONWEALT14 Of MASSACHUSETTS /Vox
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair N ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at o -1 �:� _ %c.U as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within t s of the date of this petrmit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date //-A- d -7Boar of Health
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