HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE��
COMMONWEALT14
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YARMCUTH HEALTH DEFT. -7-7,Y 94v i 7 3f
Board of Health, 1146 Rol ITF 9$ , MA.
APPLICATION FOR DISMVMV'rbfflMUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
on 3
Owner's Name dd se
Map/Parcel#
Z-/ f 7
Address 30o boo,. T- 1Ra"
Lot#
Telephone#
Installer's Name
�
Designer's Name
Address, j 3
Address
Telephone# QR41121K711
Telephone#
Type of Building Ccinko Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS L"A- u� , T"K 7i es.;14 i 0
Alec -x 7!�C
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 o place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed / Date 4,
Inspections
N..,6 O 4 ' / —'496S SACIIUSE% 5,5, FEE
COMMONWEALT14 Or
/ Board of Health; y� DI , MA.
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CERTIFICATE OF COMPLIAN
Description of Work: -4 Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
j
by: cif.•itJ ?4,) �4
has been installed in accordance with the �•ovisions, of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. I %� L; dated • `1 2 - / Approved Design Flow (gpd)
Installer ,': ' . I , V.�. P d "� �"a / �2 (C i (�.� CA
Designer: —^ Inspector ` Date:
The issuance of this permit shall not be construed as a gu .4 tee that the system will function as designed.
No. 6 0 kA D C — ? "" L, S ( 8 CPPE- ` I -k) C— FEE
f 7- 2 COMMONWEALTH OF MASSACHUSETTS
Board of Hea
Tlth, 71a � 01-14 �,MA.
DISPOSAL SYSTEM
]1 STEM CO�T�1J
ST 'l_.TIO7 PERMIT
Permission is hereby granted to; Construct( ) Repair(/) Upgrade( ) Abandon( ) an individual sewage disposal system
at UQa L� 1 ; ;._i I �. r as described in the application for
Disposal System Construction Permit No. �- /S -2L dated _ !
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 7,4 t3oard of health ✓ �7