HomeMy WebLinkAboutApp-Permit-Compliance�% /rc� ry �• r
No. O / FEE
CO6
COMMONWEALTH Of MASSACHUSETTS ( � I'
Board of Health, YARMOUTH HEALTH JFPT.
1146 ROUTE
APPLICATION FOR DISPOSAb5WV04T0A%9T4WTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade,/( Abandon( ) - ❑ Complete System-l:rIndividual Components
Location s -y - sxv 94 eek--L?a ; j
Owner's Name yZC,_✓L t,t. o k
Map/Parcel# AA cww4l z Af Ll
Address
Lot# * 1
Telephone# Y----�
Installer's Name lV`Z- �(xG�C✓Z
Designer's Name Ae /"-Oft
Address l6-0 ,a to S f IV.
Address R61 6�/14 6 3 f
Telephone# 1??g,yZ'6. 243`J$
Telephone# "I ^ 36:6�— 34424
Type of Building D✓ a Lot Size /7 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
5;4 -
Design Flow (min. required) gpd Calculated design flow !4140_ Design flow providedgpd
Plan: Date 4P - /67- c�? Number of sheets Revision Date
Title Kr 04 k e-
DescriptionofSoil(s)
Soil Evaluator Form No. Name of Soil Evaluator7&4 Nelel]40 Date of Evaluation e, -11 -fel
DESCRIPTION OF REPAIRS ORALTERATIONS 05e- rL`�•5��� f�CI0 9af�t9`2 �,i'� �L �P�-' ��d D
aJ^iI J��' rr Z� .age
The unde i ed agrees the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further gr es to n tp� a the system in operation until a Cert�cate of omp 'anncre has been issued by the Board of Health.
Signed f Date �7-1 e t
Ins ctions
FE
No E
COMMONWEALTH LTH ®f MASSACHUSETTS
Board of Health, t4( 'a v,, y ,kL, 'MA. /
CERTIFICATE Of COMPLIANCE
Description of Work: dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (-<Repaired ( ), Upgraded ( ), Abandoned ( )
by: )2 1L.1, 'f�2
at C vs2./ %f2 , r'_2 -4—
has been installed in accorda ce with the provisions of 3 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No. —14,C , dated - -G Approved Design Flow ICS (gpd)
Installer lRf (.# v'2 _ _ 1--)
Designer: &4:j ' S'✓7Ai A� Inspector: 1®/ Date: _
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,Gs�%Z
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE ---
Permission is hereby granted to; Construct( ) Repair(V) Upgrade( ) Abandon( -)an individual sewage disposal system
at 1,2g 4 [)a as described in the application for
Disposal System Construction Permit No, --�'v , dated 7 r
Provided: Construction shall be completed within4h%e�ye' 5f the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Cnadeslown, MA Date Zi Board of Health / ��