HomeMy WebLinkAboutApp-Permit-ComplianceYAHMUU I H H LI UtN 1.
No.
_ ESQ. Y MOUTH, A 02664
COMMONWEALTH Of MASSACHUSETTS
�qeBoard of Health, , 9 (jr-9 MA.
FEE ®a
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade)() Abandon( ) - X Complete System ❑ Individual Components
Location
Owner's Name/QDB
Map/Parcel#
/>
Address A1,44�
oov,?� d
Lot#, -T AW '
L19,
Telephone#
Installer's Name '�''�� !C'1f_1=k i"
Designer's Name
e
Telephone#
Donald<W "Moncevicz
CM[Engineer
40 Pond Street
West.Dennis,-MA 02670
d
Address 7Add
,e -T7- MMOU 024- 3
Telephone# 1.518 % .,�
Type of Building ZIE Zr� %.0,,XF_Aj '%0%. � � !/fie / 7-S i L t Size 99,,,2 3 4 ,,-.-
Dwelling - No. of Bedrooms %� Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow®
Plan: Date/Vdl/ 457 122 Number of sheets 9
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above
r further aees to not to place the m in
Signed -= C,
iF
Inspections
No.
Name of Soil
Individual Sewage Disposal S}
until a Certificate of Complia
e it -/-5-
Designer:
is
N
of Health,
n flow provided .330 gpd
Date
,pate of Evaluation Akv id /4n
AA,;Z> PRIOR
n in accordance with the provisions of TITLE 5 and
has been issued by the Board of Health.
CA �,C, PJ
d�
FEE
MA.
CE FICA Of CTed
PLIANCE
Description of Work: ❑ Individual Component(s) Compl a System
The undersigned hereby certify that the Sewage Disposal stem; onstru Repaired ( ), Upgraded ( ), Abandoned ( )
by:�--
at IeD/Z?
has been installed in accordance with the provisions of 310 CMR 15.00 qritle 5) and the approved design plans/as-built plans relating to
application No. dated .� �"� Approved De ign Flow _�>�(gPd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �� / /�� �J �/j/!/ i FEE r7 o.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, /Ae~U-rH MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct) Repair( ) Upgradex) Abandon( ) an individual sewage disposal system
at ta�a'F3/�IYI®fJT as described in the application for
4 B C6zE Z:Z "
Disposal System Construction Permit No. ;�2 —f -7, 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 oard of Health