HomeMy WebLinkAboutApp-Permit-ComplianceFee j J
COIYI1MONWEA JI -I OF MASSACHUSETTS e �` �� `?'
WL �?7 YARMOUTH HEALTI ,REPT.
Board, of Health, "A,
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APPLICATION ] OR DIISPOSX "��'9RWTION PERMIT
Application for 'a Permit to Construct( ) Repair(/j Upgrade Abandon( - ❑ Complete System ❑ Individual Components
Location /'7
AML 2-c (t,/.�
Owner's Name C,�t- 1��/�'�"z
Map/Parcel#
Address z �r'G iF%t "lG-west P£ W -tom
Lot#
Telephone#
Installer's Name
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Designer's Name / V
Address `
LAA C bi
Address L✓ —/P 6L
Telephone#
Telephone# '7 -7 5—
Type of Building Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder (h1%C7
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) /16 gpd Calculated design flow -5 Design Bow provided �_ gpd
Plan: Date—!-/ a ` ro- Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator C '/�
<n J e e Ld e. Date of Evaluation 9
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DESCRIPTION OF REPAIRS OR ALTERATIONS / )'V -w IsO/ �. l CP&V;ee1 P-t!+,O C-MZ01WJl-I,itl0
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not tooce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed &k -.-Date ��777 ' La -c-'Z." Inspections IV- l 'd� S t6 ok_ /V -,7-0 2, 70,ncte- 17�es ek.
No. `-`1 -;i f CC PCC
CCMMONWEALTII OF MASSACIIUSLTTS-' <' - -,. ,F
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BoardofHea1,1h, Y fi/ VIA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) R] Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired r5, Upgraded ( ), Abandoned ( )
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the .a proved design plans/as-built plans relating to
application No.-'"t-`^v'U dated -lr fly �Gt ='-�w.. Approved Desigu Flow "i" �./ (gpd)
Installer. re 7 5 ')
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llate;Designer tr(,
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The issuance of this permit shall not be construed as a guarantee that''dre system will function as designed.
No. J / V -+ lv 1 ic— PEE (+
COMMONWEALM OF MASSACPIUSETTS
Board of Health, AVIA.
DISPOSAL SYSTI, 1 CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( -"j Upgrade( ) Abandon( )an individual sewage disposal system
at i' /( 1'4, ; ,Tt as described in the application for
Disposal System Construction Permit No. dated /r=.
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Provided: Construction shall be completedwithin,threeyearB of the date of this permit. All local conditions emust be met.
9
Formt255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date A 16 Z) `-"-'- Board of Health
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