HomeMy WebLinkAboutApp-Permit-ComplianceYAR*A"'UTH HEALTI; DEPT. 779 - IC-- 00 r 75'7
No. 11ro�y.EB l£� A7)FEE SA -r 00
810. YA-RMOUTH, MA 02064Z�-
Board of Health, J , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair() Upgrade Abandon() - W<omplete System ❑ Individual Components
Location dad L'J.
Owner's Name
Map/Parcel# G' S^
Address Cl
Lot#s%S"
Telephone# .5-0
Installer's Name
Designer's Name I
Address
Address �i(sT �:akuts' P•Qo oY // .13
Telephone# s--o� s]�
Telephone# -5—e ' —
Type of Building Lot Size ��' sq. ft.
Dwelling - No. of Bedrooms arbage grinder (WO
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) //0 gpd Calculated design flow 3.33 Design flow provided =-
Plan: Date /a — f ^/7 Number of sheets Revision Date
Title
Description of Soil(s) o
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
of Evaluation
Ic
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place—the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 2! v7.� — AP
Inspections
�Q V T ! •-"r! . , 15
' + J
/
COMMONWEALT14 Of MASSACHUSET>
D�
Board of Health, Vl1 t,t 1 t ? � , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) J<omplete System "
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ARepaired ( ), Upgraded ( teAbandoned ( )
at /�'J CAa. j W- I'f. 4".1�
has been installed i acco dance with the provisio,ts2f 31D CMR 15.00 (Title 5) and the
application No. 49 dated Approved Design Flow 3.3
Installer C
Designer: T_(, r- ., i, �`rt/�„t6inspector:
The issuance of this permit shall not be construed as a guarantcVthat the system will function as designed.
No. CY— FEE Oy
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, l du PQ-Q� o
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( k�-- Repair( ) Upgrade( )_Abandon( ) an individual sewage disposal system
at J as described in the application for
Disposal System Construction Permit No, __, dated 7i
Provided: Construction shall be
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA
S-
s f the date of this
rd of Health