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HomeMy WebLinkAboutApp-Permit-Compliance1146ROUTE 28 No. SO. YARMOUTH, MA 02664 COMMONWEALTH OF MASSACHUSETTS Board of Health, �� ►�tti� k4 MA. FEE O toll APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ). Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location % C ,� O A W , Owner's Name .{ a ©S .� Q _ ^ Map/Parcel# Q 1 Address Lot# / Telephone# /V .r 76 91 Installer's Name�. Designer's Name Address 1 '1 Address 2[� ✓cC S GO Vis/ Telephone# Telephone# Type of Building S l i S A FR M 1-14 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) I / 1) gpd Calculated design flow Design flow provided gpd Plan: Date �i " % z qS' Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS �E„J �d JS C : t1 .ti �GiIITt _Tso r;, G 5�r A ��►k 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 place the tem ' peration until a Certificate of Compliance has been issued by the Board of Health. Signed Date i} S Inspections No. _ FEE 'l_ OMMONVAI' FALT1 t Of MASSAC14USETTS OQ Board of Health, 444D. 4, 4 MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) �omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired ( ),Upgraded ( ),Abandoned ( ) by: /�/t/ C d\ at / / AL/^ -e ll ! has been installed inaccordancewith the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. O r , dated :7 —'c7-eApproved Design FlowZ—(gpd) Ay Installer /9!l/X / A/'6�y� Designer: ��i l 1 //1/ Inspector: & / � Date: The issuance of this permit shall not be construed as a guarantee that th system will function as designed. Rte? ,a�✓ �. y %i S� No. � FEE COMMONWEALTH Of MASSACHUSETTS Board of Health., Lj MA. DISPOSAL SYSTEM STEM CONSTRUCTIO PERMIT Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at ! fL//. /«' as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 3 :Z "'%,f hoard of Health XL'''�