HomeMy WebLinkAboutApp-Permit-ComplianceNo. KO ��I�"�J% 44 kw t 4�� � /e FEECOMMONWEALTH OF MASSACHUSETTS
DO
YARMOUTH HEALTH DEPT.
Board of Health, 1146 Ra lis , AIA.
APPLICATION FOR DISPOSK' rMT' CTION PERMIT
Application for a Permit to Construct( ) Repair(( Upgrade( ) Abandon() - ❑ Complete System A Individual Components
Location
3(, Mock Cm'
Owner's Name 1k4AtCS 7-611(500#-*VrC&j PUT
Map/Parcel#
Address t API4ew V ik . 5O, i -rm
Lot#
Telephone#
Installer's Name CAp64AD - C-Wr&W&US
Designer's Name N A
Address 15
C �T
Address
Telephone#
50 �9 -'1 71,. -7 77Telephone#
Type of Building REQ r LTi ufrc.. 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
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS C HA u CXG C:1ye -F?-0U4- b+0 uc ;E Z O 16�T (C;-- 1018 1 K
-TN15TEu � 5,0N'tom a&J (ryc T d1F "t/4n1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o no o p ce th ystem in eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ✓-.�-ptj
Inspections
No. O N D( -1-7--3-7 t `1i /, ✓ 7�\��/lf�l % FEE
COMMONWEALTH Of MASSACHUSETTS
17-57 0Z
Board of Health, `A?nWUT`� MA. D ! _
CERTIFICATE Of COMPLIANCE
Description of Work: Mndividual Component(s) ❑ Complete System
The undersigned. hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: �!A,PGW626 60115PLA KE -S RtcN.41�j �APE1J
at. 31 MoGt<tACz13CRU 44NE
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated � -7Approved Design Flow (gpd)
Installer l 1
Designer: N /A Inspector: (/ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 600 -Dc -V7- 37q 1 �✓�-�c( l�t➢fc FEE X ��✓, Q�
7-,,;- 7 COMMONWEALTH Of MASSACHUSETTS J
Board of Health, A Nu& v -7- V4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(k Upgrade( ) Abandon( ) an individual sewage disposal system
at -31 N DGr-lA-)GL31 PI) L—Aty-6 as described in the application for
Disposal System Construction Permit No. / 7- �- 7 , dated ����,����- %i - �j
Provided: Construction shall be completed within wthme-a� tlYe5ite of this peral
/ . Alllocalconditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date - ��i /� l -?oard of Health v