HomeMy WebLinkAboutApp-Permit-ComplianceNo. '� / - �/ _ FEE 5-6
COMMONWEALTH Of MASSACHUSETTS /`j► I (e
Board of Health, 1'Af n'l0-L,*MA. Y
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (y�Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
0 1fat,r r"k
Owner's Name 441/j tr f011dA
Map/Parcel#
o� 6
Address
Lot# 7
Telephone#
Installer's Name
Designer's Name
.A
Address
350 Main Street
Address
Telephone#
W. Yarmouth, MA 02673
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 33o gpd Calculated design flow
Plan: Date I l— Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Q -e i P JAA J
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided 3'f U gpd
Revision Date /t/ 0%13
Date of Evaluation
The undersigned agrees to ins a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not . lac the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date % a
s
Inspections
No. 01 —3 FEE J C�
G Board of Health, %l1 f MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (6�-,<pgraded ( ), Abandoned ( )
by:
at
has been installed inad nce with the pro 'sions of 31 CMR 15.00 (Title 5) and thapproved design plans/as-built plans relating to
application No. '516 dated "` Approved Design Flow a,e Z% (gpd)
Installer 6e? W60 /1 - n
Designer: -U .-I
The issuance of us permit.,
No.
FEE .S
COMMONWEALTH Of MASSAC14USETTS
Board of Health, f t-4, o (n MA.
DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT
Permission is hereby granted to;
at
N
Repair( -I' --Upgrade ( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. 10 - 3 `3V, dated
Provided: Construction shall be completed withif the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dater c/,7)4 Board of Health V