HomeMy WebLinkAboutApp-Permit-ComplianceNo. �i'F ' 1 L✓� � 4 S-00 00 'l' 8 2- FEE
AOMMONWEALTH OF MASSACHUSETTS
/ B �IdofHealthYARMOUTH HEALTH DEP
MMUTE
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( )-,L;�eomplete System ❑ Individual Components
Location'2 T b
Owner's Name:Rw
i i, riC
Map/Parcel#
Address 90
TADWMCICVOPQ�
Lot# ,
Telephone#
6 00o - 2 2- g 5 4 2
Installer's Name imn
I1AC
Designer's Namemoy-oo
Eng
Address (omi ii I
d s-cnQ Q
ddress.1 L
Q arui f
Telephone#
RoS 5
1Telephone#
- 2
Type of Building ul
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow
Plan: Date
Title I Ulo
Description of Soil(s) _
Soil Evaluator Form No.
No. of persons
Lot Size" sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow 7- 0 � Design flow provided 2,6 (1 S gpd
Number of sheets 2. Revision Date 6101
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unders:
further agrc
Signed
Inspections
Name of Soil Evaluator
Date of Evaluation
to inst4l kabove escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
R
cele in eration until a Certificate of Compli ce has been issued by the Board of Health.
Date
No. 1 (J���"t 4`1:;x( E�p
COMMONWEALT1 Of MASSACHU T
Board of Health, _ Yi�ci 0l�' 1`�'� " MA. (k 2 -e
CERTIFICATE OF COMPLIANCE �, k g05118
Description of Work. ❑ Individual Component(s) 3-C^"omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade, Abandoned ( )
by.
at i �} D c� RA D 6"F- V
has been installed in cord ance with the ro 'sio sof CMR 15.00 (Title 5) and t�e,�p&design plans/as-built plan relating to
application No. �-a l , dated WApproved De 'gn Flow 61 U�
t/ ....
Installer 5
Designer: m6a �(�. l -t- J-6`1nspector:
ate: a
The issuance of this permit shall not be construed as a guarant6ellatthe system will function as designed.
No. U i O� t-- � N 1 FEE Z i:'o
Board of Health, ''w MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct ( ) Repair ( ) Upgrade Abandon ( ) an individual sewage disposal system
at c� as described in the application for
Disposal System Construction Permit No. /&I- I).- /
da ed
Provided: Construction shall be completed within etYt eof the date of this per t. WRocal condi ' must be met.
, CrJG�f
RForm 1255 Rev. 5/96 A.M. Sil kin Co. Boston, MA Date/-. �S Board of Health
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