HomeMy WebLinkAboutApp-Permit-ComplianceNo. W _2J ~ FEE_
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
42�YARMOUTH HEALTH DF�T.
,
1
APPLICATION FOP, DISPO"LY51MYMIMNMUCTION PERMIT
Application for a Permit to Construct(KRepairO Upgrade( Abandon( > ` 0 Complete System eIndividual Components
Location 'T_ Git'dA7- -4- J'o >-0
Owner's Name .P
Map/Parcel# %�-- _-----
Address
Lot#
Telephone#
Installer's Name Q5r:�,ysj ��Q�'O�i/i�
Designer's Names���fv� 4e 4W -re A'f
Address 1/y„t..��s �i� , f ,
Address
Telephone# OMSo e773
Telephone# p,? -.:2>7'
Type of Building �/
Dwelling - No. of Bedrooms
Other - Type of Building
efi
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) -7 .fO gpd Calculated design flow idp Design flow provided gpd
Plan: Date C500" Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of two place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed e/ Date Ar -4 60
Inspections
h
FEE
No.
COMMONWEALTH Of MASSACHUSETi I v 7,/U
Board of Health, VOG411 44AIA.
CERTIFICA OF COMPLIANCE
Description of Work: ❑ Individual Component(s) eComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired ( ), Upgraded ( ), Abandoned ( )
by: S" G,,dd'T _' iL►IC,!"cs+' �s►Q', �'%"✓•�l'j G,�e'�"IiJ�'t-ar.'
has been installed i accordance with the rovisions of 310 CMR 15.00 (Title 5) and th a proved design plans/as-built plans relating to
application No. Q dated Approved Design Flow (gpd)
Installers
Designer: "��"�� • ,l,3j�loY.✓ Inspector: Date:
The issuance of this permit shall not be construed as a guarantee /that the system will function as designed.
No. /i
(® doll FEE
COMMONWEALTH F MASSACHUSETTS
Board of Health, L-/ (W-d!'f/L / , M.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at �'"/'Y ��.+�.�'y�as described in the application for
Disposal System Construction Permit No. �%y -� g , dated.
C k-44,5
Provided: Construction shall be completed within of the date of this pe mita All local conditions must be met.
n /Form 1255 Rev. 5/96 A.M. Sulk in Co. Boston, MA Date Board of Health