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HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT. No. 1148 ROUTE 28 FEE C®MM®NftM%M�MMUSETTS Board of Health, hlf)WA 7 , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location G / rJ 6A_ C/ , Owner's Name t J 941# Map/Parcel# /"go `6 Address �% ��!% /�/� xlee4 G//.' Lot#, Telephone# Installer's Name �O6�i5/. Designer's Name ��jC (���� (of%��•/ Address (�s�+� �- i Address Telephone# 7 7 J --,? Q Telephone# . 1,33— 7-177 Type of Building Lot Lot Size sq. ft. Dwelling - No. of Bedrooms 5 Garbage grinder (-0-b Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) ,310 gpd Plan: Date D j Number of Title '572 %`e_ �� �7L����� ) Description of Soil (s) Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Calculated design flow Ile sheets Name of Soil Evaluator Design flow provided Revision Date Date of Evaluation y lS gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to n to plac e , tem in operation until a Certificate of Compliance has been issued by the Board of Health. n Signed Date Inspections No.� FEE 67, 10 COMMONWEALTH Of MASSACHUSETTS Board of Health, yC%'bwell1 w , MA. 04 (0 1 CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) B"Complete System The undersigned hereb certify that the Sewage Disposal System; Constructed ( ), Repaired'( ), Upgraded (V< Abandoned ( ) by: © Cr j �/�; C', -)as at / C� has been installed 'n accordance with the provisions o CMR 15.00 (Title 5) and the ap proved design plans/as-built plans relating to application No. dated Approved Design Flow��-(gPd) Installer G CJ /-7,/ Designer: &/t' nE �/%�d%1� Inspector: r Date: 1p��Cl r The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. �� � to �'^7 L� �/ / FEE COMMONWEALTH Of MASSAC14USETTS � Board of Health, �l{%7`/ MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby ranted to; Construct( ) Repair( ) Upgrade( V� Abandon( ) an individual sewage disposal system at / ` C i` ioAvfa 'i'1 Cl as described in the application for i i l Disposal System Construction Permit No. 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�V ' oard of Health /'/ ✓