HomeMy WebLinkAboutApp-Permit-ComplianceNo. ' 1 e
COMMON WE-ALTH OF MASSACHUSETTS
-ZcGI���$ YARMOUTH HEALTH DEPT.
Board of Health, tt4e-ROUTE 28 '
APPLICATION FOR PERMIT
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Application for a Permit to ConSn'UCt( ) Repair( ) Upgrade Abandon( ) - P-6mplete System ❑ Individual Components
Location 0
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Owner's Name
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Map/Parcelii
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Address 06 lojwAolve
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Lot#
Telephone#
Installer's Name (749,c
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Designer's Name
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Address36 lygh
6 LYOpm
Address
Telephoneii
Type of Building edX60 �`(� Lot Size sq. ft
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building .S e e.,, 0PZ/1. � r/�(1 No. of persons Showers ( ), Cafeteria ( )
Other -Fixtures �t
Design Flow (min. required) v3 O gpd Calculated design flow Design flow provided 720, gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
W;ZL i1 =� I \
Name of Soil Evaluator
O
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 to not to place the system in oper tion until a Certificate of Compliance has been issued by the Board of Health.
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Signed Date ,-r Date
No. C1 -r �/ COMMONWEALTH OF MASSACHUSETTS EEE 5221 :3
Board of Health, lfrx-< /< 77, , HA. r
CERTIFICATE OF COMPLIANC4F
Description of Work: ❑ Individual Component(s) U"Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,( -)-'Abandoned ( )
at '.e,_-_fi t aha" ..e- ri w --- --r' "y. -(.W-.,.. wi:' '"> �' t--s'�-?-.g'-a'�" 4�S ° C^ �L9" 1 (utile /
hasbeen installed with the rovisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
�) dated `` 1 /7' U �. Approved Design Plow '✓ fi (gpd)
application No. O ✓ ' `7�
Installer C,'/,,t/1C ..%/k ,�71h,,%/!%
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Designer: ,T/ -/V, f-) Inspector: �t . .,<_.. � Date:
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The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. L) - JJ%� / (, /�_«Sx°Cy,( 7 ,�,✓.f FCC r'C/ P tri
COMMOtN)WEALTI1 OF MASSACHUSETTS'' "
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Board of Health, /�,'' /Y1A.:
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade d.)"Abandon( )an individual sewage disposal system
at �6 ///'W'/ (,' i, 1. )lig t ": as described in the application for
Disposal System Construction Permit No. ii`% �� , datedt
U G2 ev
Provided: Construction shall be completed within iliree-years of the date of this perr*t�-,All local conditions must be met.
Form 1255 Bev. 5196 A M StAkln Co. Boston, MA Date // /7 d S- Board of Health
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