HomeMy WebLinkAboutApp-Permit-ComplianceNo.-"-:m-M3
yARM®UTH HhALI N vr-r 1.
1146 ROUTE 26
,Q. yARMOUTH, MA 02664
COMMONWEALTH OF MASSACHUSETTS
FEE
�j
Board of Health, Taf to d V 1 q , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade/ Abandon/ - U Complete System individual Componen�
Location U r'IuCr f-
Owner's Name
Map/Parcel#
Address
Lot# S
Telephone# 39!!j:----70 Z " -7 -71— 66 "' w
Installer's Name
Designer's Name��
Address 2� ��/�—
Address P�, [50 ?56 A-rm
Telephone#
Telephone# "775—ci700
Type of Building Dt/✓C?l 1 Lot Size 1 .5 6 1 S � sq. ft.
Dwelling - No. of Bedrooms ,3 Garbage grinder (&VO
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) —33c) gpd Calculated design flow 3 Design flow provided 50 gpd
Plan: Date Number of sheets 1 Revision Date
Title A -i -F Pl/�, t9, J H-ju yl-rA4e. L nj-4 . q S{ ejld,-A,1& 41. YA!r 1FjLJ, rM I u 20�
Description of Soil(s) Cl) A -/1,,-e -CA,� 4 2-1' Tn l 32- !/
Soil Evaluator Form No.
Name of Soil Evaluator R . d CAJa7kLc-Date of Evaluation 5/2 -
DESCRIPTION
/ -
DESCRIPTION OF REPAIRS OR ALTERATIONS SZ, H—/t/ >-U 4---
The undersigned agree install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n pla the in a ' �a;lE11-a Certificate of Complianp as bee issued by the Board of Health.
Signedof ADate��— 7
"Inspections
No. FEE J :^
COMMONWEALT14 Of MASSACHUSETTS
1,-
� I � 4f
Board of Health, YR 2wt O'n-1-1 MA.
CERTIFICATE Of (OMPPANC�
�\stn` ` L • 'S. t' �` �TTad
Description of Work " `nvidutalomponent(s)' Complete System
The undersigned hereby cert that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded.�/, Abandoned/
at q Site I bGJr,y A-V W- y rMO. ,7'N
has been installe m accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design. plans/as-built plans relating to
application No dated �IApproyed Design Flow -3 S --O (gpd)
Installer
Designer:�f/�f Inspector: 'f / Date:
_ The issuance of this permit shall not be construed as a guar tee that th system will function as designed.
No.FEE
COMMONWFALT14 OF MASSACHUSETTS
Board of Health,d,
(ZYYt A) I V MA. C
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is
hereby granted to; Construct( ) Repair( ) Upgrade/ Abandon /an individual sewage disposal system
at S k ,- 6 y ✓ P- W <� t > as described in the application for
Disposal System Construction Permit No. dated
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 r �oard of Health