HomeMy WebLinkAboutApp-Permit-ComplianceNo..%i
-1146 ROUTE 28
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSACHUSETTS
Board of Health, I1a1'4W4f7 , MA.
FEE
�01&44 1
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (e Upgrade( ) Abandon( ) - ❑ Complete System ❑,Individual Components
Location 14
Owner's Name Lo vr�
Map/Parcel# 7 fI
Address
Lot#
Telephone#
Installer's Name ��� %� � � Cyr ���' ��®/�
Designer's Name /O®/pan
Address y ��r��
Address
Telephone# 41 V —
Telephone# ze z — e,7 $7 S
Type of Building ,Cn-5iWeyee, Lot Size sq. ft.
Dwelling - No. of Bedrooms `7 Garbage grinder (4&
Other - Type of Building No. of persons Showers ( ) , Qafeteria ( )
Other Fixtures/,q
Design Flow (min. ��,,quir,)e)
ell gpd Calculated design flow �d� Design flow provided 'N7 gpd
Plan: Date - Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
REPAIRS OR ALTERATIONS �
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ee o la th s, o eration until a Certificate of Com�p�llianc has been issued b the Board of Health.
Signed ! Date %Z.l ? y
Inspections
No. "v �/� FEE �-
COMMONWEALTH Of MASSAC14USETTS ri
Board of Health, ,/Qi!?J®4i`f'/ , MA.
C ERTIFIC TE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (0 U/pgraded ( ), Abandoned ( )
by:
at Ll7 �l/ %i? 5��?!c' ✓� l�i'1'�lG�Ld/7`
has been installed in accor ance with the provisions o310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. dated / (p Approved Design Flow (gpd)
Installer ,,gyp
Designer: /�1OAAOV Inspector: ate:
�" The issuance of this permit shall not be construed as a guarantee that the system will function ;4. designed.