HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28
No. 80. YARMOUTH, MA 02664 FEE -0'06
,f itlew
4/0—.,Z /xoOPz,�MMONWEALTH Of MASSAC14USETTS
and of Health, MA.
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTI® P e'
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Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( - ❑ Complete System chvidual Gompon8rits °~°
Location jf'l
6;�7077
!X
Owner's Name
Map/Parcel#
Address
Lot# ?�
�� Z 75—
Telephone#
Installer's Name//
Designer's Name��'
Address
Address
Telephone#
Telephone# •- 3 Z Z
Type of Building q.
��! �`�Lot Size lv «� s ft.
Dwelling - No. of Bedrooms CV C22E'f3`�y 'Z g R- �� �6N� - 3 Garbage grinder
Other - Type.of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required ) I gpd Calculated design flow 3/ Design flow provided !'� 37 6 gpd
Plan: Date ' %� 1 J l 2 /GNumber of sheets Revision Date
Title/ P%yzn0 ,f- /-
Description of Soil(s) cSee^
�z
Soil Evaluator Form No. y )e -Z& -&V Name of Soil Evaluator "7!:�r Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agr to install the above describeApdividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
4%rther agrees t tb ce thto o hon til a Certificate of Compliance has been issued by the Board of Health.
Signed [���/G� Date !L�
Inspections
No. —IC/ 1 FEE
COMMONWF—ALT14 Of MASSAC14USETTS
Board of Health, plc, / G P) MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: P S I L ,
-t7-
at12d S�
has been installed in accorda ce with the provisions of :5/0 CMR 15.0 (Title 5) and the approved design plans/as-built plans relating to
application No. `1q ` dated Approved Design Flow f576 (gpd)
Installer F; . (-r.3 9,2 r
Designer: h—::e44T, ;, r. #S ,5�,� i Date: 1 2
The issuance of this permit shall not be construed as a, guarantee that th system will function as designed. .
No. FEE f/ U
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, 4- MA.
DISPOSAL SYSTEM CONSTRUCTION- PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at I I S C� L - LQ 6 76,Q id ZJ-1 as described in the application for
Disposal System Construction Permit No. W - 9,9' �, dated
Provided: Construction shall be completed within three years of the date of this p�*t. local conditions must be met.
F /.Cj �Form 112555 Rev. 5/96 A.M. Suulkin Co. Boston, MA Date !{ 1 Board of Health''� �