HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH LTH ®F MASSACHUSETTS
S
YARMOUTH HEALTH PEP
Board of Healt l
46 ROUTE 28
APPLICATION FOP, DiSnX R "'`MMUCTION PERMIT�=P-ee-"Z-
Application
for a Permit to Construct( ) Repair(,, -,Upgrade( ) Abandon( - ❑ Complete System "dividual Components
Location 3 (
Owner's Name
Map/Parcel#
Z Z
Address 31 P,S w P—A
Lot#
Telephone#
Installer's Names
Designer's Name
Address .v
t A?���5
Address
Telephone#
SOZ46
Telephone#
Type of Building SOJC-Law� Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to mot t la a the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signedl Date l I I13 SOT_
Inspections
ACHf n
No.y % �a S- r' (/ / FEE Js
COMMONWEALT14 Of MASS US Sa'6,, g- >Z
Board of Health, , , MA. ,
CERTIFICATE Of COMPLIANCE
Description of Work: .d'Individual Component(s) ❑ Complete System
The undersigned hZY
bcertify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned (' )
by: \
at � �*
has been installed in acc rdance with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 3 -Z�' . Approved Design Flow (gpd)
Installer r
Designer: Inspector: / L fi Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.%°NEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, C , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at %ZOO a as described in the application for
Disposal System Construction Permit No./ //n dated /���
Provided: Construction shall be completed within tbi� f the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date � � �% Board of Health
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