HomeMy WebLinkAboutApp-Permit-ComplianceA
No.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, X� nn 0 U4- , MA.
FEED
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APPLICATION FOR DI L SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(- pgrade() Abandon( ) - ❑ Complete System ❑ Individual Components
Location Z/8
Ahrm- 'm
Owner's Name
Map/Parcel#
20-1
Address
Lot#
Telephone#
Installer's Name
A & B CANCO
Designer's Name Ertcf
Address
350 Main Street
Address
Telephone#
Yarmouth, MA 02673
Telephone# - O
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date 3
Title
Description of Soil(s) (-
Soil Evaluator Form No.
I
gpd Calculated design flow
Number of sheets r
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided -Y 7 t' gpd
Revision Date ✓U I R
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS P{ r- G `� I �c- k)
The undersigned agrees to install above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not ace sys in operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed !Date lU
Inspections
,a
r / s �e Z-7
No. 2 -._f .,1- ('�' ��]�~ � �,,. FEE
COMMON �� �:1" LTAF MASSAC14US ETTS �w
Board of Health, ,,{'`� � % /y) , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( pgraded ( ), Abandoned ( )
by:
at m i4 Z1, t -/ A % >'� i ✓'J 0) -
has been installed in accordance with the provisio s of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. n. -:5i l , c, , dated !i i7j Approved Design Flow (gpd)
Installerc'-
Designer: l �`'"'�tl ��' /��c��' - Inspector: Date:It
r
The issuance of this permit shall not be construed as a guar(ntee that/the system will function as designed.
No. / vC �' C �+ ` ' FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, MA.
Permission is
at
DISPOSAL SYSTEM CONSTRUCTION PERMIT
granted to Construct(
rpgrade ( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. 6 , dated �f
Provided: Construction shall be completed within-twee%mss of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date U Board of Health Ci(