HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH OF MASSACHUSETTS 7�/
e (,41YARMOUTH HEALTH DEPT %
Board of Health MA.
46 ROUTE 28
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APPLICATION FOR DISPWSVRMTY,��MITRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - ❑ Complete System 1Andividual Components
Location/ F-
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Owner's Name /+10 // j 5 Vv ,-
Map/Parcel#
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Address �- %. j I VY !1
Lot#
Telephone# S-pb' 3 7 „s— G S 0
Installer's Name izl
Designer's Name
Address a
Address c93J
Telephone#
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Telephone# S / 3 d' - 3
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures ``C%
OP I
Design Flow (min. required) 7 gpd Calculated design flow Design flow provided3. . gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) 6 er' So/ '1 LG
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
signed Date
Ir .pections
No. Oci i / �"� .✓ :�s FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �. / t MA. t `
CEPITIFICWE Or COMPLIANCE
Description of Work:dividual Component(s)
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The undersigned hereby certify that the Sewage Di:
by:
at t h i s� _ �' it o ✓ '}
has been installed in ccordance with the rovisfot
application No. —172—, dated'•
Installer I r 5 rir C/ h/' S C?
❑ Complete System
sal System; Constructed ( ), Repaired ( ), Upgraded'), Abandoned O Soi 1
CMR 15.00 (Title 5) an the a oved design plans/as-built plans relating to
Approved Design Flov —l;Vgpd)
WG'G! lLY �s
Designer: Inspector: Date:
The issuance of this permit shall not a construed as a guarantee that the system will function as designed.
!'U ; FEE /U
Board of Health, `..- �'► , MA.
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DISPOSAL
CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No
Provided: Construction shall be comple
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat