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HomeMy WebLinkAboutApp-Permit-ComplianceYAi" iMUU i M ntR I. h utr i . rr No. 5� 7 1146 ROUTE 28, i - FEE ` 30. 00 SO. YARMOUTA MA 026644 66 ® COMMONWEALT14 Of MAS AC14USETTS Board of Health, MA. APPLICATION FOP, DISPOSA SYSTEM 'CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ). Upgrade( ) Abandon() - ❑ Complete System U Individual Components Location e V Owner's Name 6j Map/Parcel# #19 Address Lot# -Z- 6Zi� Telephone# Installer's Name N S C4�tJ Designer's Name Address G Address Telephone# 6Q Q`j� Telephone# Type of Building- � Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. Plan: Date / Title gpd Calculated design flow Number of sheets Lot Size No. of persons sq. ft. Garbage grinder ( 0 Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation The,prafersigned agrees a ve cribed Individual Sewage Dispos S t in accordance with the provisions of TITLE 5 and f ther agrees o 1 e t o eration util a Certificate of Co pli has been issued by the Board of Health. igned Date A 'Inspections No. COMMONWLALT14 Of MASSAC14US ETTS ') �VJ4Board of Health, 14 r tY?? o U CERTIFIAT®F COMP ANff Description of Work: The undersigned het by: - at � has been install application No. Installer I di 'd al C n nt() r-1 Com let- Q+-- FEE • V y n vi u ompo e s p ys o6by cert' that e Sewag Disposal System;Constructed ( ), Repaired ( ), Upgraded, Abandoned ( ) C 17A 1 S�Y t /qf n nJ -/j C- cco � Adfe with the prd'visiols/off3370 .,CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to �7 �7rdated �� �� -9/0. Approved Design Flow �TL/ (gpd) Designer: l�i4y , e WKS S O A.! Inspector: jgge W /1 Date: � � �'7 � U The issuance of this permit shall not be construed as a guar tee that ie system will function as designed. No. �(J Y ? i 7 (I() 77 ON FEE ,-so- i it COMMONWEALT14 Of MASSACHUSETTS ao 60,; Board of Health, r• ~ a u4 , MA. DISPOSAL SYS CONSTRUCTION PERMIT Permission is hereb granted �at 7ni(-7r©, ) r=' l ( ) Repair( ) Upgrade) Abandon( ) an individual sewage disposal system `�,., / as described in the application for Disposal System Construction Permit No. vV 5 dated Provided: Construction shall be completed withintkrFez1;-e`ars of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ` Board of Health 6 !'