HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1f5 DC'` -)-396- /-7 C 7', '/'' � �,a% FEE V�' O�
_"o COMMONWLALT14 Of MASSAC14USETTS
Board of Health, YARMOUTH HEALTH UT.
1146 ROUTE 28 -WM4JCTION PERMIT
Application for a Permit to ConstructX Repair( ) Upgrade (} Abandon() - )(Complete System U Individual Components
II Location 1.A4-AS/PL0u1L/e /ROAO `V-YARMLIT14 I Owner's Name%70H/4 �r'�''SA _ 11
Ma /Parcel# Add ss V 0A YAC/Frit c,e+wfi,l�«vw y fF/��f
P 30 137 �c,G / GA X08 3
Lot# j;L0/ Telephone# gitq _ge g_ 0Z 3
1e/SS!-/.vG Designer's Name
Installers Name ,�iQ/►aN C.g
Donald W. Moncevicz, P.E.
TJ,dress 17 lbw/ -j QR00k /�D. Address Civil Engineer
phone# O 6 7 7 S'^' d't 4Y Telephone# 40 Pond Street
/r West Dennis, MA 02670
Type of Building O,E'/.1Lot Size T4 sq. ft.
Dwelling - No. of Bedrooms 3Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow ((min. required) 33O gpd Calculated design flow Design flow provided 3 S'7 gpd
Plan: Date APIP, aOl % Number of sheets Revision Date
Title t � Ft@d%�C2S:cr% —<3A 1f -r,4 .,y S)--JM^4 i%�4D� t•
Description ofSoil (s) -10AV ci-.IA4
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 to place the site/m in (ration until a Certificate of Compliance has been issued by the Board of Health.
Signed !. y,« a,. �,i C' (! ,aL1t1d A&A.'m Date '?t t-a't i
' ' Inspections (a
No. o�'i�-3i �' FEE
vv�
COMMONWEALTH OF 64 MASSACHUSE� �� : � , � � �
Board of Health, >!,�q !S. ,MOv7" MA.. •� % �""°
CERTITICATE�OF COMPLIANCE.,
Description of Work: D Individual ComponenL(s)`Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (, Repaired ( ), Upgraded (, Abandoned ( )
by:
at �.a ��?%�'Lo.DtlJ�'/Q /�oRP I,�t,e►r�Sr" e4/�'JYl8V7'L+1
has been installed in accord4nce with the provisikAns of..K0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , _dated % `.. Approved Design Flow 0 (gpd)
Installer ( la K l `S t_t iJ
Designer: Awaij> W. Ai amc rt l cC Z Inspector: U J Date: r2 % ri�7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE 00
COMMONWEALTH or mssmuusms
Board of Health, , ,.YAR~tJT'f-1
DISPOSAL SYSTEMCONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgradeo< Abandon( ),an individual sewage disposal system
at�Y�®c��/F' ,'c►�o /L/Wsy- yAWL as described in the application for
Disposal System Construction Permit No. /!ff , dated
Provided: Construction shall be completed within three years of the date of this permit., 1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA + ate ! 4 Board of Health