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HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28 SO. YARMOUTH, MA 02664 'd FEE �-• P - -A Board of Health,MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair( ) Upgrade Abandon( ) - X Complete System D Individual Components Location ,�-7+ �^ m2 Owner's Name � P1�11�. OL Nj) Map/Parcel# %�, 3 Address 10-7 0Adr-HA4A 02.&,38 Lot#.-?� 2-5 Telephone#0,9 Installer's Name , N_ i Designer's Name Donald W. Moncevicz Address mef " 3 ( -7� Address Civil Engineer 40 Pond Street Telephone# q 5bf,s(, Telephone �' West Dennis, MA 02670 Type of Building9;; A00At7 -Zfi/. -�- L'hirr'SJ Lot Size ®. 2.3 46 Dwelling - No. of Bedrooms / :;7wA,4 Garbage grinder "40 Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required)® gpd Calculated design flow Plan: Date�ii� S/ of Number of sheets Title'r�R�S.�I� Si�•�!T/�/�,� �Y-��P'i�/�/� �PG/��if%� s Description of Soil(s) _ Soil Evaluator Form No. 4�.jf''�Rr41to DESCRIPTION OF PATH nu at r ti rz a rT�nic Design flow provided 3.3e gpd inion Date Name of Soil Evaluator. Wd►NC ICZDate of Evaluation .4Ajv PRer R_ , .3v,-j&gn+-',#� L%ci17-S A/L' %''V B A i'"d' .�/�AOCt/ 4ae/4YY2:'Y �y-S7' iE/I /'/V Or- i4 fyAjoiEriA_- /4/Z /9 mgoVAD anF3w/ovc, Me, /e ,jam. e -Z ( 2-_.!wX'7S) XArv'Lr"P Ag'[s R., ZO©o Apex, /now /ver RPR/C,91in AIF, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr s to • not to place the tem operation until a Certificate of Compliance has been issued by the Board of Health. Signed C ADate S- 3 / - Zoop s Inspections No. GCl tC/ FEE,.$®. ®O COMMONWEALTH OF MASSACHUSETTS Board of Health, >Aeeow f MA. "t t,7 CERTIFICATE OF COMPLIANCE � (D Z Description of Work: ❑ Individual Component(s) Xcomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired ( ), Upgraded)<, Abandoned( Y at has been installed in accordance with the}�rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 10 30? , dated (D - S-t.+[J Approved Design Flow _33Q (gpd) Installer ;;yy F l�QI�/ ,�l�//C.. Inspector; Date: Designer: The issuance of this permit shallnot be construed as a guarantee that a system will function as designed FEE COMMONWEALTH Of MASSACHUSETTS Board of Health,.e/Hdyy'�y/ MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission isshhereby granttd to; Construct�l Repair( ) UpgradeX Abandon( ) an individual sewage disposal system at A�!'mix G. omr, ��r' _ 'fas described in the application for Disposal System Construction Permit No. "' �3fZ , dated 6 Provided: Construction shall be completed withi �/� rs of the date of this it. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 6 _5__&V Board of Health