HomeMy WebLinkAboutApp-Permit-ComplianceTAMMUU I M Mt:AL IN Utt' I.
No.
1146 ROUTE 28
SO. YARMOUTH, MA 02664
Board of Health,
FEE ,
P409'1:�-2S2-,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
2 `S �C/ %
Owner's Name
Map/Parcel# N
7
Address
Lot#
Telephone#
Installer's Name
!) U f? co
Designer's Name IFA
Address 6
Z.d/1
Address r &V7-kGd-T
Telephone#
Telephone# -_?C a ,, I;;- / 3
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Design Flow (min. required) 10 gpd Calculated design flow J 30
Plan: Date C& ` 7 C9 Number of sheets
Title
Lot Size sq. ft.
Garbage grinder
Showers ( ), Cafeteria ( )
Design flow provided gpd`
Revision Date a}
Description of Soil(s) _ k e 00 1,6
Soil Evaluator Form No. Nam9-0 of � dA S Date of Evaluation -7
DESCRIPTION OF REPAIRS
,�:--
% n, 1? G
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 Iflulace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date S a
Inspections
No. FEE S V
Board of Health, MA.
CEPITI ICAT ®F COMPLIANCE
Description of Work: ❑ Individual Component(s) 0'6omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
by: / 0c, J-�r
at 3 Cst 1 P "I e -le S fnbti
has been installe accoJ dance with the provisions of 310 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No. ; 7f �dated 9q . Approved Design Flow ,'7� (gpd)
Installer t ---a "
Designer: Inspector:Aoalu
-'Y-4� Date:
The issuance of this permit shall not be construed as a guarantee that thl system will function as designed.+,
FEE C+%
COMMONWEALTH Of MASSACHUSETTS
Board of Health,'!x'."-"`, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (% Upgrade ( ) Abandon( ) an individual sewage disposal system
at (,u ,C 1-3 !3 t" rt ' S 19A -r -t s'T t��� duG+ 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.
Farm 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date~?Aoard of Health _ �'
is