HomeMy WebLinkAboutApp-Permit-ComplianceNo. fir, 't"R Pe)w) r
� 6Jy"/Q �L+f� FEE
CO�'l[MOO T ICTH Of MASSAC14USETTS GIf�GC
Board of Health, 'kLK0 J MA.
aL
• ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit toC tstruct Repair( ) Upgrade Abandon( - )(Complete System ❑ Individual Components
Location 34 &Apcigo /qVAS-. Owner's Name %AVW0L11f `p rt0V p► 5V--„
Map/Parcel# g� Z Address S&O PAW -W
Lot#J60JLoi)j6 M, 57 -oF 7/ �i��•����> Telephone# g® - 334—,0.,r61
Installer's Name bQ)AM C. 1<15 -V -14G, Designer's Name � Donald W. MonCevioz, P.E.
Address -7 TS N Address Civil Engineer
w'Wj7" *Y�'l"N 40 Pond Street
Telephone#S106 -778-OL/W I Telephone# West Dennis, MA 02670
i
Type of Building %Z,05/D 1.0t.size 12,1�ter
Dwelling - No. of Bedrooms joeSi GlJ s-MMDAM` 0 Garbage grinder (N®
Other - Type of Building No. of persons Showers ( ) , Cafeteria (
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow -330 _ Design flow provided T� gpd
Plait: Date '%/AJ AC5, 2D/ -7 Number of sheets eN15 Revision Date
Title ie/ )R, -OP 5,5P SY-5'7MM t1PG,,:ZAPC-v1 _
Description of Soil (s) lid
Soil Evaluator Form No. Name of Soil Evaluator &&CZ Vj r,7. Date of Evaluation JQAi !a A0/-7
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees 4 not to place a syste in operation until a Certificate oft Compliance has been issued by the Board of Health.
Signed i Date CJRJ(1 o�mj 2d l %
Inspections
No. G) �C _, �%" �"I l7 j FEE
COMMONWEALTH OF MASSACHUSET 6y 12 -61 --
Board of Health, MLIMA MA.
CERTIFICATE Of COMPLIANCE
Description of Work; 0 Individual Component(s)Complete System
The undersigned hereby certify that the Sewage Disposal System; ConstructedRepaired ( ), Upgraded (, Abandoned( )
by: CGe--,j&(2-AL- CO ,J'
at
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.'' dated ^'t Approved Design Flow (gpd) +� , ��•}
Installer p-(�_i_� C f ''-� --
Designer: f�a iV kja ector:
The issuance ofthis permit shall not be construed%as a guar tee that ti.
l COMMONWEALTH 01
�I
at
Disposal System Can!
Provided: Constrict
® form,1255 Rev. 5/96 A M Sulkln Co.
7ste °,"III funUioi
STRUCTIG%T. P.
an individual sewage disposal system
as desCribed in the application for