HomeMy WebLinkAboutApp-Permit-ComplianceNo. % �— �``� 1146 ROUTE 28 FEE . .40
SO. ` ARMOUTH, MA 02064
Board o Health `�tl-�--t—o 0 � MA.
f ,
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - ❑ Complete System ❑ Individual Components
Location ;ZA*-
3 3 `Q X V,*, Ssi e�-
Owner's Name O e [..
Map/Parcel#
l
Address 190.Ma.
Lot# LqTelephone#
3 6 L —
Installer's Name
4�c�Le `
Designer's Name
Address
3 `�
Address
Telephone#
Telephone# — 41
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date i l
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS 13
It oo—
No. of persons
Lot Size YV1 OL3 sq. ft.
Garbage grinder (/W
Showers ( ), Cafeteria ( )
Design flow provided 4164 gpd
Revision Date 6
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 agrees to not to lace the system in operation until a Certificate f Compliance has been issued by the Board of Health.
Signed wa =1, Date ¢_ A / `? /
Inspections
No. / / �J FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 17 t oy i MA. C.
�T
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) OSComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (%df Repaired ( ), Upgraded ( ), Abandoned ( )
by: lA,ce * ? ^t C
at `�G°) - `3 25 . �,,-y-e- -QV. .,r o..r-- v—o V-4— p o "'CZ,
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _7'! �.Z S dated%1 Approved Design Flow -PI"4(gpd)
Installer 4
Designer: e, e;/ 5r ��/(/trT/�[/_ Inspector: Date:
The issuance of this permit shall not be construed as pguarantee that the system will function as designed.