HomeMy WebLinkAboutApp-Permit-ComplianceV FEE+W
MMmoN3 LTH Of M ASS CHUSETTS a
Board of Health,
YARMOUTH HEALTH D,PT.1146 ROUTE 28
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APPLICATION FOR DISPOMLy9"W",MMWCTION PERMIT
plication for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ❑ Complete System C7Individual Components
Location I
aRJDd--T WC -79 7 e?JJ �V
Owner's Name W t OTEQa,,NFre <: "t74 -t. (A eJ j)
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name C14-eELU(-D6 fv-r7Ek-pp (5C' f
Designer's Name
Address 53
earl, Z�dA�. ZT I "l { gaPEL--
Address IZ574 CR 0-04
Telephone#
5.0 P - 47 7 _gg -7 -1
Telephone# Sd � - a-73 -- 0 3 -7
Type of Building R12� t V ANT I Pot Lot Size ( Q, d g 1'C sq. ft.
Dwelling - No. of Bedrooms �-t Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)gpd Calculated design flow Design flow provided 41504C1 gpd
Plan: Date (O -act '-.-Lo ( i Number of sheets l Revision Date
Title I �'RBkZ k606R*3 sou -M
Description of Soil(s) !
Soil Evaluator Form No.
It jpttEDjo&r qadl St -r-
Name of Soil Evaluator K -Pt VLit?-rrZS1- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS L) -SG e J -'-rt NG -r 1, 6 Q0 GA ct ) St�ttc TWN V, T'0
I�b� Glx -tv (3) 5 oo 6A-gLotj 14 -�-o c,�g �<x ao�5 to t'rA 4 ` o�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree to no place the system in o eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 6-3 0 f 7
Inspections
WS
No. bo{j1QC-� -7 -y8 i
COMMONWEALTH OF M A ACHIJ IJ
Board of /7-- /ft— Health,U(J / ni , MA.
CERTIFICATE Of COMPLIANCE,
Description of Work: W.Ifidividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed(—), Repaired (), Upgraded( ), Abandoned ( )
by: 0106.Jt D 6 LQII7aQPAf 1$—ej21CNA i�2 Ci �iE�N
atI --iQ16:4T CcJr:E-
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. �� /f dated :7-27--1 Approved Design Flow and
M(gpd)
Installer C. L 1014 A 0Z l EN i
Designer: ZL DJE,LX'EZE (X.X---2AJC Inh
The issuance of this permit shall not be construed as a
Date: o
that the system will function as designed.
No. U C-7-HS96 0W FEE t5 . 04
7-- /Fr COMMONWEALTH Of MASSACHUSETTS
Board of Health, )AM U U -T14 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ('Abandon ( ) an individual sewage disposal system
at� Q BQ- 1 I JF -675W k) A 0 N as described in the application for
Disposal System Construction Permit No. /� �' " dated 7 -%> -
Provided: Construction shall be completed within t elte of this permi . All local conditi - must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date J-; - / Board of Health ( C /�
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