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HomeMy WebLinkAboutApp-Permit-ComplianceNo. P -A)K 5 (e-& ii- f! / Y FEE / Board of H 1146 ROUTE 28 ealth, 2W APPLICATION FOP,�, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgradepo Abandon( ) - ❑ Complete System Individual Components Location C—C'n' Owner's Name ^/ ^ o Map/Parcel# <1 qX023 Address (0 1 Lot# Telephone# Installer's Name p� Designer's Name Address T&>, Address ® Qo Telephone# 5o$_ Telephone#$ �•i� _-C�S(� Type of Building "� Z&e_y i, 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) \X0 gpd Calculated design flow `1/410 Design flow provided gpd Plan: Date %1A116.3 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 %JAQO 3 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further t not o ace the y t in operation until a Certificate 4Mhas been issued by the Board of Health. Signed Date Inspections No. FEE COMMONWEALT14 Of MASSAC14USETTS : 'AYR, Board of Health, - ai - ^�'� � MA. CERTIFIC �®F COMPLIANCE Description of Work: Chi Individual Component(s) ❑ Complete System The undersi�7ed hereby ce,,r, ft thto tie Sjewage DispoR,al Systerp� Constructed ( ), Repaired ( ), Upgraded (/Abandoned ( ) by: y °r` v I ,U IJ I Fes' '-1t"°e i iv(, at%�! has been installed in accordapce with the provisions of 310 CMR 15.00 (Title 5) and thq.approved design plans/as-built plans relating to application No�} i i :,, .^%t `21' p dated ` . 7'" Approved Design Flow (gpd) Installer i ,K- ' Jll �`��3`", ° -: j 1f . ,-; ° Designer: 1 {N jV1UrQ(,r_.rj i t. -C.- Inspector: X hA,':7t/` ° �' Date: The issuance of this permit shall not be construed as a guar t e tha he system will function as designed. No. 6 3 / FEE Permission is hereby at COMMONWEALTH OF MASSAC14US ETTS Board of Health, 1 , 0jV MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT to; Construct( ) Repair( ) Upgrade( ` Abandon ( ) an individual sewage disposal system Disposal System Construction Permit No. flJ%i dated as described in the application for Provided: Construction shall be completed within three years of the date of this permit. All local conditions,must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 1`7 Board of Health . 4040 No. � / COMMONWEALTH Of M:� � ���� /,�� �� 7 YARMOUTH HE / Board of Health 46 Roj ITF 28 MA. APPLICATION FOP, DISAXfMM�MSTRUCTION PERMIT Application for a Permit to Construct)(f Repair( ) Upgrade Abandon( ) - ❑ Individual Components Location &/ Owner's Name" " " 70" 4j � Map/Parcel# ! � Address &r Lot# Telephone # (' `7 7_, r— Installer's Name Designer's me Donald W. Moncev' Z, P.E. Address 2 TOL01,13c Address CIVII Engl r 40 Pon Street Telephone# Sb Telephone ., West De is, MA 02670 Type of Building diJ.S Size, �® sq. ft.' Dwelling - No. of Bedrooms Garbage grinder (© Other - Type of BuildingNo. of pers ns Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculate design flow 4,40 Design flow provided !449 gpd Plan: Date UG �.%. _24W3 Number of heets Revision Date Title /�� OF Description of Soils) S19'I�/ a Soil Evaluator Form No. Name o oil uator W Date of Evaluation DESCRIPTION OF TERATIO S lc)e4wl Ala'. The undersigned agrees to install the above des ribed•Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es to not to place the t m ' ation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 4r ^ Z + Q Inspections '11� ®A No. -o—M COMMONWEALTH EALTH ®F MASSACHUSETTS FEE Board of Health, ����4 , M7A. U" C ERTIFIC�E OF COMPLIANCE Description of Work: XI Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed (Repaired ( ), Upgraded (Abandoned ( ) by: t r at has been installed in acc rdance with the provisions o ,33 CMR 15.00 (Title 5) and h proved design plans/as-built plans relating to application No. dated !� 'Z I . Approved Design Flow (gpd) Installer Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. ® Q No. L/! i FEE COMMONWEALTH Of MASSAC14USETTS Board of Health, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Cort'structX Repair( ) Upgrade) Abandon ( ) an individual sewage disposal system at 61 G �i2�•' as described in the application for Disposal System Construction Permit No. ®-3 dated Provided: Construction shall be completed within.t4P@e-years of the date of this permit. (t/A/1,l local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date � Vf3 Board of Health Li'