HomeMy WebLinkAboutApp-Permit-Compliance1146 ROU :2i FEE
80.YARIVIOUTH, MA 02664
COMMONWEALT14 Of MASSA�YUSETTS
Board o Health �� MA,
APPLICATION FOR DISPOSAI SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - A Complete System ❑ Individual Components
Location I l' c 4 Ji
Owner's Name jo- in
Map/Parcel# I,� lA
Address �+� �I GX Is S.
Lot#
Telephone# 3 �,� d 6 Z/
Installer's NameDesi
ner's Name
g S�cefscs
i�f 1
Address ya'AJp ,.7 v
Address S .,e l�/es7�e. •�. %?� C be m r
Telephone# _ 3
Telephone# 3 9�.� a
Type of Building Res /c/Pnf; I i/4j jj 0me-
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
P- 441
00,61
W6
Lot Size �,�,1 sq. ft.
Garbage grinder (} A/V
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mint. required) 33 0 gpd Calculated design flow -ONE- Design flow provided 33.?. -� gpd
Plan: Date/� / Number of sheets Revision Date
Title
Description of Soil(s) 0- 9-ld4'l 5,q,7cl. �� � ' dUm �� ca� � "t-1.20 � 4.�c� .
Of
Soil Evaluator Form No. Name of Soil Evaluator S&,ee tsef� Date of Evaluation '
The undersigned afire 0 to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to the to on until a Certificate of Compliance has been issued b the Board of Health.
Signed Date
1
1.4
Inspections
No. /
FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, 1A 1A
CERTIF�ICT Or COMPLIANCE � o�
Description of Work: ❑ Individual Component(s) Complete System
The undersign d hereby certat the Sewage Di osal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: f ,
at
has been installe accordance with the provi 'ons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. -� 4-U, dated /1 -319- '? 7.'Approved Design Flow % 3Z-- "(gpd)
Installer « 0 A,6,it
p p
Designer: 429Inspector: Date:
The issuance of this permit shall not be construed as,a guarantee that the system will function as designed.