HomeMy WebLinkAboutApp-Permit-ComplianceTANIVIUIJ III HLAL1 ti UEPT.
No. — IV- 1146 ROUTE 28
SO. YARMOUTH, MA 02664
FEE S-C)
—
dr: t it Y17.
Board of Health, , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair* Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location �� gj (L�` ���
Owner's Name
Map/Parcel#
Address Ct �"rx-s, cx.
Lot# fo
Telephone#
Installer's NameO
Designer's Name
Address --�S0 �`� ,5.�.����
Address
Telephone# -� -� _� _ p�
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
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
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the rovisiQ 5 and
further agree to no e e system in operation until a Certificate of Compliance has been issue 1p�tl l ' ,
Signed f �a..r.. Date ltWu
MAY 4 5 1998
Inspections
No. t FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health,MA.
�ERTIFICATE Off' COMPLIANCE $'<r 5 ,rl 'f j-) -oc,�►
Description of Work: ❑ Individuatxomponent(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( )
by: Now to
at !I 3"(�c`-1 % l r A
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. q (7 2 , dated 5- 7 r Approved Design Flow (gpd)
Installer ,s
Designer:' Inspector: ii o �� `�/� �- Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. q
CO[MONWEALT14 OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
issr�b�'ed to; Construct( )& leµp(� Upgrade( ) Abandon( ) an individual sewage disposal system
at / � '!� �� C A P�'v"- u y as described in the,hpplicadon for
Disposal System Construction Permit No--"j ��i�` , dated
a Provided: Construction shall be completed within tears of the date o this p r it. All local nditions must be met.
t Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �J7 &K Board of Health