HomeMy WebLinkAboutApp-Permit-Compliance1146 RQ)UTH 28
No. �Zti-L" FEE
S®. YARNvaOUTH, MA 02004
COMMONWEALTH Of MASSACHUSETTS
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(KUpgrade() Abandon() ❑ Complete System O"Individual Components
Location /-3- YLtJ C'cg--), RV 5d - y4le
Owner's Name / t o givIr % orlf 12) f
Map/Parcel# - Z �
Address /,>' 10V%O7 ,�Voo3 Oil
Lot#
Telephone#
fnstaller's Name C4 /V co
Designer's Name
Address 13 -5'd 57'
Address
Telephone# ,sd r 7 7,5' - ,Z p6
Telephone#
Type of Building
Dwelling - No. of Bedrooms,
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 6 O X V o�4,4 C £o'J f ti'
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to not to place the sys in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. 179 szz C®MMONWEA��� Of MASSAC14US ETTS FEE
Board of Health, t-//}t2!4F y YTS' , 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 ( )
at /5" A64 �l&[mssyo!b he 5Q �,�tf
has been installed in accordance with the provisionsCo 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application . q ? " S—o , dated - / . Approved Design Flow (gpd)
Installer ye�!—A- ��
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that Ze system will function as designed.
No.ice..//7u�� FEEC
Board of Health, _ /!'!O?/ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (6 Upgrade( ) Abandon( ) an individual sewage disposal system
at / '� A4,r ,� a �"°t`//+ G as described in the application for
Disposal System Construction Permit No. 9Y- S-6 dated .2 ` 7
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 7_- _�1-- '�i Board of Health L. -f
h — )Z^ ./ t) A// Y / r