HomeMy WebLinkAboutApp-Permit-ComplianceNo. - / l3, cL as FEE.M
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for ,aJJ••Permit to Construct() Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
'LL /A / A 4 A
Location Lo
Owner's Name Walden Corp/Robert Dunphy
Map/Parcel# 46 2/3
Address 541 Main St., Harwich
Lot# 2
Telephone# 4 3 0- 4 7 0 0
Installer's Name PKM
Designer's Name Sweetser
Address Hokum Rock Rd Dennis
Address Great Western Rd,Dennis
Telephone# 385-5993
Telephone# 3 9 8- 3 9 2 2
Type of Building Single family dwelling (2
Dwelling - No. of Bedrooms / S
Other - Type of Building
Other Fixtures
l e x Lot Size 64,464 sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) (O V V gpd Calculated design flow KJU (J Design flow provided M / f1 b gpd
Plan: Date 1/30/04 Number of sheets 1 Revision Date
Title Proposed septic design ,Lot 2 Town Brook Rd West Yarmouth
Description of Soil(s) See plan
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 afire o n t to pla ate syst m ' operatio ntil a Certificate of Compliance has been issued by the Board of Health.
igned � Date /
Inspections
i rivrl� y� d i`int >
No. _ 9�- 22. -O j FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, d MA. 776e
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s)rrrromplete System tl
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded ( ), Abandoned ( )
by: �'7i� ,�'�
at / A40 6D
has been installed in accordan with the of 3 0 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No. 01"IL dated '.•� Approved Design Flow (gpd)
Installer / / .// / 8' — ce� � s— A
Designer: Inspector: Date:
-®-l%
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
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No. `� l / FEE ✓ dEf
COMMONWEALT14 OF MASSACHUSETTS ,.i,�Zj7,/6g
Board of Health, ,01- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby
( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at C2 / / , ax S -2--f
} as described in the application for
Disposal System Construction Permit No. a9 ""'� , dated O
Provided: Construction shall be completed withir>ro, rs of he date of this permit. All cal conditicmust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Bost 'n, MA Date 1 -2 ^V Board of Health �""