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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1143 ROUTE 23 SO. YARMOUTH, NIA 02D34 0MMONWEAEF11 OF MASSA1 IIUSETTS Bomd(fllrallk, )ko'lMt��`�J Vll. FEE - •� APPLICATION FOR DISPOSAL SYST]:M CONSTRUCTION PI1RMIT Application fora Permit 10 Consu-uct( ) Rcpair(I,1 Upgrade([ ) Abandon( ) - UU Complete System ❑ Hidividual Components Location % II// dv , dry , Owner's Name lJ Map/Parceltk � �j Address Lot# Telephoncif Installer's Name (J����%�/ �'©y���'- Designer's Name - Address �— �'�S �. fe/ Address f3? "e'7'x"9r per% Telephone# �� 'Telephone -0k �� —eI5 V Type of Building A e,7.AY'ej1G e Lot Size Dwellinv - No. of, Brdrnom.c tip Other -Type of Building No. ofpersons Other Fixtures sq. ft. Garbage grinder ('Q Showers ( ), Cafeteria ( ) Design Plow (min. r/red) �%� gpd Calculated design (low ;��iC3' Design flow provided tl� gpd Plan: Date 6IJ6- l't �J Number of -sheets / Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Nance of Soil I$ahtato- DESCRIPTION OFREPAIRS ORALTERATIONS )`_1/_1e -iZ &79:/%Z� Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t hot to lac/�ee t,he system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed j%t✓' Date 412 2-h" ' Inspections No. 67,9 —,2 S � PEE COMMONWEALTH OF MASSACHUSETTS Board ofHtallla, MA. CERTIFICATE EDF COMPLIANCE Description of Work: ❑ Individual Component(s) M Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (6)xupgraded ( ), Abandoned ( ) by: 0611 1 c. e"'-I't' r c G' 01W AW has been installed in Yccordance with the provisions of 3d^1;0 CMR 15.00 (Title 5) and the . pproved design plans/as-built plans relating to application No.. %' :%2 �•3 dated G "�z'�+`/d5. Approved Design Flow (gpd) Installer 156,,Z%1L ©!71 �BsV-> L J`% .mm, n a Designer: ,1i°lCLCAAI Inspector: JCA ez 12 dam¢ Date: ;7- a) A The issuance of this permit shall not be construed as a guarantee that the s�stem will function as designed No. J� `� ��-.,_) ,6,9177V L. e)77/ C. IT.n/..5� FEE _Z) COMMONWILALTH OF MASSACHUSETTSek 17(o Board of kallh, i�� � ✓'/ �YIA. ��" DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygrantecl//to; Consu-uct( ) Repair( Upgrade( )/ Abandon( ) an individual sewage disposal system at !° /t// &W ,/{11 Sau'4%e/ d+d''ir/'�+'T`�i as described in the application for Disposal System Construction Permit No. 91f --53, dated 64; l F 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. Sulkln Co. Boston, MA Date t' Board of Health