HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 20
No. 3 �-- $®. YARMOUTH, ROTA 02664 FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(xlupgrade( ) Abandon( ) - ❑ Complete System ❑,Individual Components
Location
Fr -c -t P i2 CQ
Owner's Name
F0
Map/Parcel#
Ct Cj — S0 0 3
Address
-LrAkvt,e-
Lot#
Telephone#
Installer's Name
f a
Designer's Name
1
yVtY�'
Address
—3. j 0 YV-C, A
Address
Telephone#
"�'7 ; - c) -R6-6
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
re- S .
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gPd
Plan: Date p / Number of sheets Revision Date
Title /ST
S N/\
Description of Soil(s) 10 (14 tA,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS L -C, i P kri
The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to c th6 system in operation until a Certificate of Compliance has been issued_ by the Board of Health.
Signed V Date
Inspections
No. / a ' S ✓
COMMONWEALT14 Of MAS SACH SETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
FEE S i
l
Description of Work: windividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (-Upgraded ( ), Abandoned ( )
by: e""qw v
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. � ` Z dated /1 "��` �% Approved Design Flow and
\�
Installer
Designer: Inspector: Date: -/ -
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
L
No. �; �--� - - - -- -
C /%T. �C U FEECOMMONWEALT14 OF MASSACHUSETTS
s
Board of Health, 1� 41--k • , MA. 1
DISPOSAL SYSTEM, C®NSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (✓'f Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
S -i5--- --
Disposal System Construction Permit No. /�" 5��; dated 2
as described in the application for
Provided: Construction shall be completed within three years of the date of this perm' All to al con itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date L27 dBoard of Health G /-