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No. �-/ q i�LPTP--t7-0051 ��/X' /; FEE
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COMMONWEALTH OF MASSACHUSETTS 0�4 322%
Board ofHealth,YARMOUTH HEALTH DERA,
1146 ROUTE 28
APPLICATION FOP, DISP094A8*9$V44h(WWUCTION PERMIT
Application for a Permit to Construct(VRepair( ) UpgradeVAbandon( ) - 06mplete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# _
Address S-
Lot# 16-
i
Telephone#
Installer's Name Ce G3S
Designer's Name DLJ
Address -Fb-044
Address ,
Telephone# a
Telephone#
Type of Building �$c�L��t� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( a
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 4140 gpd Calculated design flow 33 O Design flow provided 3 4-3' gpd
Plan: Date ->~' / Y - Xx, I Number of sheets Revision Date
Title D •- ,��',s,Lz- /�' 's
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator/Ari AIl.dC`� Date of Evaluation S 3 aZ0/-,"7
IL
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 syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed / Date G S Zc 1 /
Inspections
No.1 I^%42-aq FEE .j+ 0C
COMMONWEALT14 OF MASSACHUSETTS -7
7-1
Board of Health, V 4A(xMA.
T
CERTIFICATE OF COMPLIANCE
Description of Work. ❑ Individual Component(s) a Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed. k), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at c .
has been installed in accordance with the rovist s of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
Z...
application No. 7-1-2-01 dated Approved Design Flow gr (gpd) 77
Installer s ut �C '
Designer: i 1ij j -C Inspector. v t�C./ Date; 7- 777/ 7'
/
The issuance of this permit shall not be construed as a guar tee that the system will function as designed,
No. C "� !' "f0..CY FEES Dc^
i
COMMONWEALTH OF MASSACHUSETTS 322"7
Board of Health, MA
DISPOSAL, SYSTIACONSTRUCTION PERMIT
Permission is hereby granted to; Construct(vr Repair( ) Upgraded(/) Abandon ( ) an individual sewage disposal system
at C7 4 CA0, j 44E W - - l l c as described in the application for
Disposal System Construction Permit No/7 `l dated '(DIr 7
Provided: Construction shall be completed within tk=a4 c3f� date of this per i All local condlit4lqns must be meta
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health , �✓
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