HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALTII OF MASSACIaNSETTSV11A.
FEES
Ifa Board of Health, /� I r I xla-t/ , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION ,PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - ❑ Complete System O Individual Components
Location
Owner's Name MCL
r;A�
Map/Parcelit /01—
Address
AYyI
Lot#
Telephone#
Installer's Name
A & B CANCO
Designer's Name!sE
Address
Yarmouth,W. MA 0203
Address
Telephone#
Telephone#
3Co d
Type of Building k23 1 Lot. Size sq. ft.
Dwelling - No. of Bedrooms "� Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other -Fixtures
Design Flow (mien. required) 3 O gpd Calculated design flow Design flow provided 353 gpd
Plan: Date P/� �- I Number of sheets % Revision Date 4/V lei
Title /- /,, � ' ^
Description of Soil (s) e !47I
,
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS r�PV` P /+4A/
The undersigned agrees to install t above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
„ further agrees to not o lace t] s/ys em in operation until a Certificate of Co plim I been issued by the Board of Health.
Signed ( CCC, Date %��
Inspections
No. -" " 9 .?i G��t /"lLr°iro° /tt. " FEE �..1
C�OMMONWEALTI-I SOF MASSACIIUSE' TS ,
pw
Board of Health, J d P I 1 a ✓Y MA
CERTIFICATE OF COMPLIANCE
Description of Work: LI Individual Component(s) ❑ Complete System
The undersigned hereby cerrti'ffyy that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade(,/e\), Abandoned( )
by: C. ✓ s(..JC� C.i ..
at aC) ti/ i/1
has been installed in ac
application No. 1115
Installer
Designer: r ,did^"(,f.'Y'0
The issuance of this permit
...
No. i) "n..." .
ancdwith t'0 sprovisto is of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
ate , elated 1119 L 5. Approval Design Flow .+a- ? (g )d)
Ir � htspectot�,�"'\_.� �C,vf "��/�' �`'fe'.,N'' Date:
;hal not be construed as a guarantee duat the system will function as designed.
FEC
COMMONWEALTI-I �I MASSACHUSETTS
Board of Health, �",JOF.! t d/ r N , MA. r�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hTbygranted to; Construct( ) Repair( ) UpgradeW) Abandon( ) an individual sewage disposal system
at
W
as described in the application for
Disposal System Construction Permit No. O�/7 ` �/, dated ID ~ (C
C✓ �FL�
Provided: Construction shall be completed withinthree-y'tars o Che date of this perqtit. All local conditions must be met.
Form 1255 acv. 5196 A.M. Sulkin Co. Boston, MA Date Board Of 1-lealdl �f
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