HomeMy WebLinkAboutApp-Permit-ComplianceNo. poi 1� V { FEE
7-12- / COMMONWEALTH OF MASSACHUSETTS
/-1 `i z el 14el ` YARMOUTH HEALTH DEPT.
Board of Health, i 146 ROUTE 28, MA.
>./���.1[�T�®N® ����®RA
]CY'r!UCTION PIMST
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon() - System ❑ Individual Components
Location
56-A\({jff Zj AVS
Owner's Name PAJt<E�S A,,'g C
Map/Parcel#
fA,A-P k Cl
Address pd Ba)( (:�V% 05Z V (C,
Lot#
t -OT- 319
Telephone#
Installer's Name
CA P�� t � ���j � �
Designer's Name UC
Address t
! T
Address
Qq5�t(!AA91i9W 94
Telephone#
Telephone# .5V9- "4-Z 3 -D. -2
Type of Building R C ' 1 b ew--t l A .. Lot Size� � (t,T � sq. ft.
Dwelling - No. of Bedrooms - Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date 3 -3c- C (:I Number of sheets f
Title
Description of Soil (s) l^
Soil Evaluator Form No.
Name of Soil Evaluator
Design flow provided 275'5,3- gpd
Revision Date
Date of Evaluation 3 r t
DESCRIPTION OF REPAIRS OR ALTERATIONS 570577+CL 106W C 5CO / 1000 (A <�Glst MP-T'&cmof ✓epTlC. -
i off•' � � l�c:�l� ��d-r�ci3� 1►t% i.1 z1�J t7 --�, F�iG �L (�-C�i �t2C 3 �s Gbd�,�c�3��.�
to � F l ct_1)
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 lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 4-(,-Q
No. o . c -1 � 3 3 � F'TIS7 �e i2< ECOMMONLTH OF SNAC
Board of Health,a, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) GLC-omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: Gtfh�Fiestlli_ ��iT�RPR1St-��l�-C°11w�
at 1:3 1 ZEA EW A097
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 4�j- 7 / . Approved Design Flow ed)
Installer
Designer:_� jW Inspector:
The issuance of this permit shall not be construed as a guara
Date:
the system will function as designed.
2 �y Q
No. i- C - � �'J C7 ! lJ C1VE W ibC— FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, I A !Z 112UZA , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at (� �y/� as described in the application for
Disposal System Construction Permit No. 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. Charlestown, MA Date Board of Health
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