HomeMy WebLinkAboutApp-Permit-ComplianceNo. �3
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S// 12? Board of Health, 1146 ROUTE 28
y 13 YARMOUTH, 64
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade 4' Abandon( - 0 Complete System l- Individual Components
Location 6734 W ` , +�
Owner's Name
Map/Parcel# / v" —39 J 7
Address
Lot#
Telephone#
Installer's Name �7- /LJ� (-
Designer's Name
AddressA0 16"1 ,f IA �W
Address � �� & / PT
Telephone# 8V9—,019— 2-5 �j
1 Telephone#
Type of Building 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) gpd Calculated design flow Design flow provided �W gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The unAside to install above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further o p tem in operation until a Certificate rnli ce has been issued by the Board of Health.
Signed Date �r/'4`
* Inspections `0 f" ';to/ l�__e
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No. —7•� j �S _ l/,� FEE
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COMMONWEALTH OF MASSACHUSETTS e& s y7 �� a�'773
Board of Health, akA,1 C4, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 21ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (—J—,Abandoned ( )
by: l��%la� 7 CH7L:� S ._. A/C
at 63A ti'J /iz M-1'1/! ao W
has been installed iccordance with the pro�usu ns of 10 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. ay` 73 , dated `7 42 7. Approved Design Flow (gpd)
Installer %2_0 T e QLD —_r_06.
Designer: &A6 -LE Inspector: �� (/ �P Date:
The issuance of this permit shall not be construed as a guarantee Wat the system will function as designed.
No. f L� r�'5� �/%� FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ! �L r/U� , M.A.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(,") Abandon( ) an individual sewage disposal system
(r/ J lel// L L 11¢7V/�
at w �/ as described in the application for
Disposal System Construction Permit No. C� �7 / , dated
Provided: Construction shall be completed within tj:,�" of the date of this permit. All local conditions must be met.
9 � r
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date' �`` �� / Board of Health