HomeMy WebLinkAboutApp-Permit-ComplianceNo.y .-� —:V Z__G4a Z-7-- FEE
I
°fARMOUTH HEALTH DEPT.
Board of Health, 1146 ROUTE 98 , MA. P- keu)(
APPLICATION FOP, DISPO lR- ' MUCTION PERMIT
Application for a Permit to Construct( ) Repair (�rade ( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
ee
Owner's Name
Map/Parcel#
--8
Address
Lot#
Telephone#
Installer's Name
A & B CANCO
Designer's Name
l .f
Address
350 Main Street
Address
Telephone#
W. Yarnicuth, MA 02673
Telephone#
0i E-- ?
Type of Building? Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONSP W
Design flow provided gpd
Revision Date
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 ace 5e tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 4 Date 3
Inspections
No. J J FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, XI1100 MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersign/er by,certify that the Sewage Disposal System; Constructed ( ),Repaired (akdl graded Abandoned ( )
by:
at��
has been installed in accodajure with the provisions o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f45'), dated Z Q . Approved} Design Flow -� (gpd)
Installer
Designer: 12 ZZ Inspector: -( , Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. '�/'3.. 3-
FEE � � ---
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �` - �� ' . , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT �ax � %�'
Permission is hereby granted to; Construct( Repair ( �pgrade( ) Abandon( ) an individual, sewage disposal stem
at - �-)_! K A %6Pe L V 4 V 1- J- as described in the application for
Disposal System Construction Permit No. 1` '"'�, dated -1 _�
Provided: Construction shall be completed within t1�P of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston. MA Date -4 LJ Board of Health ��� �