No preview available
HomeMy WebLinkAboutApp-Permit-ComplianceNo. to .`_S FEE /0 4 A9# COMMONWEALTH OF MASSACHUSETTS �a Board of Health, YARMOUTH HEALTH D��VlA. pT�. , � APPLICATIO;R,pRi,( DISP®SA]�1146 HOU � , M UCTIOLN PERMIT Application for a Permit to Construct()Upgrade()Abandon() - Complete System ❑ In Components Location / 9 % � r 13 or g D W, !IX ti/o It, 7-/-i- Owner's Name t,> o t. Ups F /1-7" Z� Map/Parcel*A3 /� %Z Address JO +,dt>� IC rOw7-* Lot# Telephone# -Z7,f 7 ?D '7'2- Z 3 Installer's Name o Designer's Name Address t.L 5 Address 932 O n -c 4:A Telephone# C2, 1 % 7/ 7 j / Telephone# /ey aVV. Type of Building Z. Lot Size fd-)0220 sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building l41Tj4G f Ft~ D 6j /+P- , No. of persons Z Showers (2.) , Cafeteria ( ) Other Fixtures Design Flow (min. required) ;/ OU gpd Calculated design flow ? Design flow provided 333 gpd Plan: Date Number of sheets Revision Date Title Description of Soils) 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 of to place the system ' operatio until a Certificate of Compliance has been issued by the Board of Health. Signed Date / a - Inspections No. 21S�Z FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, 61)�e,410A_ , MA. -CERTIFICATE Of COMPLIANCE � � ;t Description of Work; LJ Individual Component(s) dComplete System The unde ' ned hereby certify that the Sewage Disposal System; Constructed (Repaired ( ), Upgraded ( ),Abandoned( ) by:7 BILI 04-t577`j4 at 5! -7-,4 g6 AL has been installed in accordance with the. provisions of 3310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to application No. l- 5 dated /2 Approved Design Flow (gpd) Installer L 0 Designer:_DAkgAli) Inspector: i Date: The issuance of tins permit shall not be construed as a guarantee that the system will function as designed. FEE/- C®MMONIWLA]LT14 OF MASSACHUSETTS Board of Health,';? MA DISPOSAL S YST CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon( ) an 'individual sewage disposal system at ( t�/2(-3 LV r as described in the application for Disposal System Construction Permit No., dated Provided: Construction shall be completedwithinthxj'%-of the date of this ermit. Alla ocal conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / � _l/Sr✓ / Board of health /.� 77 i /.� %5l-•.�- i �aA .r / i/J_.�:-�.ri.n a ,. w�..,.