HomeMy WebLinkAboutApp-Permit-ComplianceN � YAt�MOUTH HEALTH DEPT. FEE WC,
COMMAj4=,9A VA;�AC USET S
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair)_ Upgrade( ) Abandon( ) - ❑ Complete System KIndividual Components
Location 3 O p (' p $ / $ 7' .S a %t'�Q, f'
Owner's Name C £ O R C /A .1 FN //C OS
Map/Parcel# .25
Address - O OC Vf f s S ri9R
Lot#
Telephone# .Sd SB - �S8
Installer's Name A Y 4 Mc G
Designer's Name
Address 3 s0 41A-, %77AV YAR
Address
Telephone# Sol' 7'% S A too
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.
ays F
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
DESCRIPTION OF REPAIRS OR ALTERATIONS 1'".41� .41A_ -1r
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrew to not to place the system ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed0 A._ Date ' 3
Inspections
q,
No. { �V
COMMONWEALTH OF MASSAC14US ETTS
Board of Health, V a2 .<i+PGd•-, MA.
CERTIFICATE OF COMPLIANCE
FEE —XV, Cr
Description of Work: d Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.kj, Upgraded ( ), Abandoned ( )
by: A X od C ) N c o I Sc- 'eq 14 /N sT it/ -
at 30 oL C C U s i" 57- -30
has been installed in accor`dane with the
application No. 1t5' , datedg
Installer
0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
Approved Design Flow — (gpd)
Designer: Inspector,CBS/ &� Date:
___TILe_sSuance_of this permit shall not be construed as,a guarantee that the system will function as designed.
No.7 L kl
�OMMONWLAITIJ Of M SSAC14USETTS
Board of Health, V17-t�-%f , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
IJ
FEE
Permission is hereby granted to; Construct( ) Repair(,)('f Upgrade( ) Abandon( ) an individual sewage disposal system
at 30 � O S L, 5 7` -77 'Ea �i I -e 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 per 't. All local conditions must bexnet.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date (y f � Board of Health v //