HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE SCS
7
COAT MONWEALTII ,QPt� A�$$A� a�.
Ap lication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name
! G({ L - 146 ROUTE 28
Board of Health, e. YARMOUTH, „�(�1' g4
o�
Map/Parcel# — (3
k l�
APPLICATION FOR DISPOSAL SYSTEM
CONSTRUCTION
PERMIT
Ap lication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name
(� U
Map/Parcel# — (3
Address
A
L.ot# 7p
Telephone#
Installer's Name A & B CANCO
Designer's Name
Address 350 Main Street
yalrpow-, MA 09673
AddressW.
7
y�
/%K11� e,
Telephone# I
I Telephone#
Ji -
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
t.
Design Flow (min. required) gpd Caleulated design Row
Plan: Date Oct- 6, o % Number of sheets �
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS ORALTERATIONS;p
Lot Sire sq. ft.
1 tT S (%"i"� Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided 4/ `� gpd
Revision Date fJ/1'
Date of Evaluation
The undersigned agrees tom I the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no t planthle system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. ;,.)/ FEE J} o
C�Ot�'IMONWEALTII'OF MA.SSA4 IIUSETTS
r
Board of Health,_
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The hereby cundersigned that the Sewage Disposal System; Constructed
g Yertif ,ra Y g P Y O, Repaired (e); Upgraded O, Abandoned ( )
at `t Z tP �f7 Jacor 9xl�t�lf e c�a�
has been installed in accordance wid the provisions fof 310 CMR 15.00 (Title 5) and the
pproved design plans/as-built plans relating to
application No. !.'.2.✓- "`moi:i? dated ��- J''`�/ Approved Design Flow °'�^''' (gpd)
Installer
Designer: f_.�°'`f:'l� Inspector: r'8.t',<.p.� Cs¢' [.F'�/^x�c;:.k:::...,Date:
The issuance of this permit shall not be construed as a guarantee tha�the system will function as designed.
7
No. f""t �A
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ya"11,11 , Mtl.
DISPOSAL SYSTEM CONSTRUCTION MERIT
FEEe
Permission is hei�eeby granted tq; Construct( ) Repair( t,,)'' Upgrade( ) Abandon( ),,in individual sewage disposal system
j ✓ / 'i
at ) e a P �yt. �✓ ?J� /c�, as described in the application for
Disposal System Construction Permit No. 01` "%,. ,dated 42- -)-U✓.
6 14'ed
Provided: Construction shall be completed-within-ekree-years of the date of this perny t All local conditions mus): be met.
Form 1255Rev. 5/96 A.M. SuMn Co. Boston, MA .Date 4V Board of Health ✓' C -P