HomeMy WebLinkAboutApp-Permit-Compliance5TH HEALTH DEPT.
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No 'erROUTE;3 FEE
SO. YARMOUTH, MA ®2x 64
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ,���� v rV( , MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( WIRepair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
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Location
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Owner's Name
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Map/Parcel#
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Address //
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Lot#77
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Installer's Name�u
Designer's Name S'�,, j &��� 4 X44
Address,�
6 Q W e
dress ���
� W0-573-Z--)�5
Telephone#
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Telephone#Z
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Type of Building A�5 Lot Size a ®-7J sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (lefo
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures CCJJ
Design Flow (min. required) /� gpd Calculated design flow 4 Design flow provided T%, O gpd
Plan: Date 4 p/LI(- �g%� Number of sheets l Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
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DESCRIPTION OF REPAIRS OR ALTERATIONS
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Name of Soil Evaluator Date of Evaluation 8 �6
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The undersigned a ees to install the above described Individual Sewage Dis -sal Sys em in accordance with the provisions of TITLE 5 and
further agrees to place the sys min op n until a Certificate of olmpli ce been issued by the Board of Health.
Signed Date
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Inspections
No. COMMONWEALTH ir.ALTH ®f MASSAC14USETTS FEE /
Board of Health, �/,/iJi!flZ,f , MA.
OMPLIANCE
Description of Work: ❑`Individual Component(o -�D Complete System O�
The undersigned hereby certify that the Sewage Disposal System; Constructs 4- ), Repaired ( ), Upgraded ( ), Abandoned ( )
at Fec, 5�,�/�/�� r� �/ �it� L9 L a -1 0<-11
has been installed in-accorda ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 3" `I'c� . Approved Design Flow _(gpd)
Installer n l (. JK 011 i" / c Q
Designer: b�-/1/254 Inspector: Date: -,)-(o
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ! 0 'r��T VLSI//L/ G l�JT� FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; ConstruJcg- j Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at / !1 �.la/c'�!/✓�&2,eel'-� -ZeE77 as described in the application for
Disposal System Construction Permit No. 9 , dated je'
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. _
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date` hoard of Health C.-�