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HomeMy WebLinkAboutApp- Permit-ComplianceFEE Board of Health, j 1,66 FjfQ111 E ,3 , MA. APPLICATION FOR DISPOSVNW WCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrad�Abandon( ) - I J Complete System ❑ Individual Components Location Owner's NameDLIM Map/Parcel# PLA -4N J�UDV- 2-3 V5' Address 2,S &91 644A-W-V� Lot# ' Ep -11 V Telephone# -7 -7 S"— 7 `/ S-3 Installer's Name j V� L(,�, (� Designer's Name 1 LL a g72 4k^-13 Address ?0 -71)2_-71)2_ I.� Address 23!!� Telephone# Telephone# y Type of Building Dwelling - No. of Bedrooms Other - Type of Building No. of persons Lot Size sq. ft. _ Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS V P 6 A*r3C5� l� 5 r d DL -rU V066 6 6ki, J --r- The undersi ed agrees to install the ve described'Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire o not to place the in o ation until a Certificate of�ompliance has been issued by the Board of Health. Signed Date 4 • 24 Z� Inspections No. OZ �%- COMMONWEALTH E1 �1LTH Of MASSA 14USETTS FEE � l�lll`�JL Board of Health, L.KA-0 Lt -r , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Y&mplete System r1% IA The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( ) by: I4©LLy7'a-.1-- SOW CU C_NESTt a T! 0 0-J 60 C , at 2-F> O.1 CkA pec- ACO C has been installed in acccordancL.with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. Q 6 , dated <f ,,� `O Approved Design Flow 3 3D (gpd) Installer J tYw1 F-5 1 Designer: Id IWA-M L,6-l6V7jmk0)J Inspector: f,1OL- 0-1 Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. FEE..-_ No. (1 COMMONWEALTH Of MASSAC14USETTS Board of Health, V k9 -111,W to 1-14 , MA. DISPOSAL. SYSTEq CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at 2 S Cly e-14AD�" t,+.k) as described in the application for Disposal System Construction Permit No. 02 .dated E,2-7-6)/_... Provided: Construction shall be completed within t Fe �s of the date of this per it. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date (5- r2 7,-/) 2-1�oard of Health (24 No FEE COMMONWEALTH OF MASSACHUSETTS YARMOUTH HEALTH DEPT. Board of Health, 11dR RCII ITE 9R MA. APPLICATION FOR DISPOM ��'MWtCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 2-9 C 1 D 6- Owner's Name `M Map/Parcel# 14 M0 11 Pe -11 Address -Z.0 CA -f e_pm W"or Lot# OLr) ate- Telephone# Installer's Name Fl.M .- Designer's Name -01 Lt, L4 iFa, er'z^A-i-J Address B0 x 7�Z h,I�-� 0 il! $ %►q Address Telephone# D Telephone# q Z Type of Building Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. required) Plan: Date Title gpd Calculated design flow Number of sheets Lot Size No. of persons sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date gpd Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS ?_JF2LACe_6 C"3 s A0 a L- lel L_ -ria l bb -D The undersigned agrees to install a above described"Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire to not to place th tem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ► �i7 ` ?-- Inspections No. COMMON �14 Of MASS HUS TS FEE Board of Health, �l� �T , . CE OMPLIA Descriptioivi Componentr Co plete System The undeify tha a Sewagel Sy m; Constructed ( ), Repai d ( ), Upgrade!Iq4 ( ) by: at has be installed in acc dance with the visions 310 CMR 15.00 (Title 5) and the approved design plan s -built plans relating to appl' tion No. dated Approved Design Flow (gpd) Installer Designer: NZ ector: Dat Or The issuance of this permit shall n be construed as a arantee that the system will function as desiggo No. FEE L,O Old �N' EALT It Of 1` ASSA'i,�tJt1J TS BoarNHeealth, T /MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. , dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health