HomeMy WebLinkAboutApp-Permit-ComplianceNo. /Q —/X00
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®MM® ]CTI OF MASSACHUSETTS
,#YARMOUTH HEALTH DEPT.
d of Health, , MA.
F®I, DISPOIRVS ''M JCTI®N
FEE
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for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - �Komplete System ❑ Individual Components
Location -r7/ G ' A, .;i Sew v eg
Owner's Name
Ito S a 2) e JE 14o
Map/Parcel#
Address
2 ,.a, �
Lot#
Telephone#
Installer's Name
Designer's Name
2 i "V/ Y r�
Address
Address
Telephone#5 o F -,p 7 s` i 4 7 7 yf3 6' e,7-,ej-jr
e,7—,et
I Telephone#
Type of Building A C S Lot Size sq. ft.
Dwelling - No. of Bedrooms 9- Garbage grinder (/�
Other - Type of Building
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) d gpd Calculated design flow 3 3 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
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 o not to place thesystem ' opera ; n til a Certificate of gpmpjiance has been issued by the Board of health.
Signed Date 4! �210
h�Qr
No. FEE
COMMONWEALTH Of MASSACHUSET
Board of Health, �� G2 /' 0 y 9 /t ; M4„7 �; iS Z6
CERTIFICATE Of COMPLIANCE Tr -41.
Description of Work: ❑ Individual Component(s) etrComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgra&4,(r , Abandoned ( )
at y A ),v So W
/
has been installed in accord nce with theDD-visions of 310 CMR 15.00 (Title 5) and t app ved design plans/as-built plans relating to
application No. �%� dated 7 A� Approved Design F(gpd)
Installer
Designer: 1- /AQ n i= A-, j`a YIa 2 Inspector: V Date: -e—>
The issuance of this permit shall not be construed as a guara tee that/the system will function as designed.
No. �C / ��7 J`7`.�. `� FEE ov
COMM® / LTII OF MASSACHUSETTS
Board of Health, / r' 02 6 6/ T/ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( -1--Abandon ( ) an individual sewage disposal system
at C In /�% - o e,, 12 - A7 as described in the application for
Disposal System Construction Permit No. dated
dated f J
Provided: Construction shall be completed within ills -e -e -years -of the date of this perrnyit. All local conditi s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date p / " ��/' Board of Health ')1� / v Y-,//
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