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HomeMy WebLinkAboutApp-Permit-ComplianceFE.E N ARMOUTH HEALT ,DEPI'; -/ GiG Su ` Board of Health,�r; 4��^v Trc28 , MA. )k C0 ?--7-00C,ezL APPLICATION FOP, DISPMATAR"MA-�MUCTION PERMIT Application for a Permit to Construct( ) Repair(/pgrade( ) Abandon( - ❑ Complete System ❑ Individual Components W Location ouepQ— Owner's Name Map/Parcel# 63 Address 3V 4mqz R Q) V71 Lot#417 yQ Telephone# Installer's Name �—Vl/j nrsov Designer's Name E Address J0/ Cjpq b aWu kn, 5. Address 6 Telephone# 50— 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 Lot Size sq. ft. Garbage grind" No. of persons Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date O C) Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS j PO (rJf%IDI AJ6. A,C Z-A 4Aj6- AVI-40 6/~M, The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreV to not to place e s em in operation until a Certificate of Co pw.li ce has been issued by the Board of Health. Signed Date ^g Inspections T C t�. • Za..z t No.� COMMON ']L OF ASS ITS Board of Health, CERTIFICATE OF CO[P�LNCE Description of Work: ❑ Individual Component(s) ❑ Complete Syste'' �J The under, igned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded V<Abandoned ( ) by: U i� ri �X S OA at ?1-1 "-n t'JtE has been installed in acccordVnce with the pro 'sin s of 310 CMR 15.00 (Title 5) and the pproved design plans/as-built plans relating to application N . 00' J �_..� dated �i ��% . Approved Design Flow (gpd) Installer +<^j 1-to �1 cf �X n 5(ly'l Designer: l: e 1— t--+!\. �1 The issuance of this permit shall not bed _ No...t. ©tea Inspector: Date: rued as a guarantee that de system will function as designed. CO9[[MONWEALT14 OF MASSAC14USETTS Board of Health, Va ✓ lV zn�, MA. DISPOSAL. SYST M CONSTRUCTION PERMIT FEE Permission is hereby granted to; Construct( ) Repair( ) Upgrade (',4--Abandon( ) an individual sewage disposal system at aUcl G(� Ci ► P `..�'�' V IQrKM/VV't Vk- as described in the application for Disposal System Construction Permit No. 'y� �' dated v Y o Provided: Construction shall be completed within t ersof the date of Ais perrYA All local condi ' ns must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Heal / /�,th 8(