HomeMy WebLinkAboutApp-Permit-ComplianceT/ArIMUU 11'1 r1tAL1 N Ut:V 1. O06
'�No. % � 1146 ROUTE 28 FEE
SO. YARMOUTH MAO 64
CIIUSETTS
COMMONWEALT14 OV t_. Board of Health, M14 =
�T , MA.
APPLICATION FOP ➢FISP® AL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade b ,don() - ❑ Complete System ❑ Individual Components
I )AJ1 SAA
Location
Owner's Name
Map/Parcel#
Address .
Lot#
Telephone# ,7 .
Installer's Name
r Designer's Nam���/
Address
dress �
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder.jW
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
L� y� -� `r
Design Flow (min. required) f� gpd Calculated design flow Design flow provided �'o � gpd
Plan: Date `J Number of sheets � Revision Date
Title L
Description of Soil(s) _
Soil Evaluator Form No.
G6
Name of Soil
Date of
DESCRIPTION OF REPAIRS OR ALTERATIONS � /..%/�®i/ 74�4 4 ---
The undersWtoto
install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrcee&�;on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 2,5 /
Inspections
No. / _ v s— FEE'
COMMONWEALTH Of MASSACHUSETTS
Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) I Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded () Abandoned ( )
by:
at /02-
has been installed' ac rdance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. �%` OYS dated `�7 . Approved Design Flow (gpd)
Installer o/- /- l S 6%� S .
Designer: _Pe,— //L Inspector: 4eakftx CV eAWIC"Cate:
The issuance oguarantee that the
f this uermit shall not be construed as a uarantesystem will function as designed.