HomeMy WebLinkAboutApp-Permit-Compliance14
No. `.' FEE
COMMONWEALTH Of MASSAC14USETTS
t., 3 YARMOUTH'HEALTH DF�PATa ��(
;.$ Board of Health, 1146 Q� 5 28
a APPLICATION FOP, DISP® MR'N' *UCTI®N PERMIT
pp ication for a Permit to Construct( ) Repair(L1/U`pgrade() Abandon() - ❑ Complete System l'Individual Components
Vj
L cation C71-0 aa,,. -ti -r A434 -0e- �.j
Owner's Name e „i��
a�to
Map/Parcel# 13-1
Address 9,o
Lot#
Telephone#
Installer's Name °1Z,iAhRJ L fA9V-rCG
Designer's Name MOM^ \
/Y1u+h A4C,
Address 6 + q �fj^
Address , /aM
�'"W '
Telephone# ^ S'Q5 6
Telephone# if�.
Type of Building rRS��� + ,� J Lot Size LT' i3 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) l 1 4 gpd Calculated design flow 1+4d Design flow provided gpd
Plan: Date 0 -g-0? t% Number of sheets Revision Date
Title
Description of Sdil(s) 0y�dl
Soil Evaluator Form No. Name of Soil Evaluator A4" /' f-4," Date of Evaluation T ^ &I
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree no to place th sys in ope tion until a Certificate opf� Compliance has been issued by the Board of Health.
Signed t Date 6 - 8''09
No. 7 -.2 EE G
COMMONWEALTH OF MASSACHUS ETT ��� �-wi- /
;V
Board o Health GLLIGL�' MA.'
f ,
CERTIFICAT®F COMPLIANCE
Description of Work: C�Udividual Component(s) ❑ Complete System
The underjsigned hereby certify that the Sewage Disposal System; on iructed ), Rep 'red ('(Upgraded ( ), Abandoned ( )
by:
Raz,n �4'I SeZ with j
at ;k 0
has been installed inacco dant with the rovisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No.1 dated `U 7 Approved Design Flow pd
InstallerG a 4 m
Designer: A4111m A TKt. Inspector: Z44 Date: 'e- 2
The issuance of this permit,.5hall not be construed as a guarantee that the system will function as designed.
No. - �`' a /y FEE
COMMONWEALTH OF MASSAC14US ETTS
Board of Health,�T , MA.
DISPOSAL SYSILM CONSTRUCTIONPERMIT
Permission is hereby granted to; Construct( ) Repair(�Upgrade ( ) Abandon(
at go a
an individual sewage disposal system
_ as described in the application for
Disposal System Construction Permit No. T-64 da/ted
Provided: Construction` shall be completed within *- o the date of this Wit. All local conditio must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -t/,) Board of Health �4 L -