HomeMy WebLinkAboutApp-Permit-ComplianceNo. &+fl)C-l / -L&l FEE 4575n4,00
COMMONWEALTH OF MASSAC14USETTS
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YARMOUTH HEALTHT. F�T.
Board of Health, ,
6Y'+
APPLICATION FOR DISPOSWR WMTRTftWfJCTION PERMIT
A plication for a Permit to Construct( ) Repair Upgrade( ) Abandon( -
❑ Complete System kIndividual Components
Location
� �� 5 -S"' 1'���� � �
Owner's Name 'gree WA-A:b -M
Map/Parcel#
L�a g a
Address "�,4 Cjgos woep s Bval W* -Pae -
Lot#
Telephone#
Installer's Name 7L w l �� -� t
Designer's Name NLA
Address i�
�� t,4 e, �-� l�s�
Address
Telephone#
500.- 4'7-1
Telephone#
Type of Building Ru -s 1, b oy 1 164 L-- 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
DESCRIPTION OF REPAIRS OR ALTERATIONS -�C-A-u SF-PTi e �L
X"sTALL- &Jew 0-004
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 not lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed = C S " Date 4-30 X� 7
Inspections 7 -12--l'
-7_ o Z
No. aQ `1 %+B9� E C7
COMMONWEALTH Of MASSACHUSETTS
l / Board of Health, Y&_4sIoU?M-f , MA. �1
_l
CERTIFICATE Of COMPLIANCE/k/w/��%�
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( 1 Upgraded( ), Abando ed ( )
by: (A?6Lt3!7)E E!U70ZR2(SC-
at 9 C P,055
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated -/7 . Appro d Design Flow (gpd)
Installer l E
Designer: WAInspector: Date: 7
_The issuance of thispermit shall not be construed as a guar ee that the system will function as designed.
No. 1 C4A05W ( IX— 1 � PV -(54-=5 FEE
7, COMMONWEALTH Of MASSACHUSETTS 2 -
Board of Health, YA?�o on-( MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(x) Upgrade( ) Abandon( ) an individual sewage disposal system
at lrrZ U S -T Q as described in the application for
isp`r�al System Construction Permit No., dated
Provided: Construction shall be completed withinahr ars ol?"the date of this permit. All local co itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date L- /7 Board of Health L