HomeMy WebLinkAboutApp-Permit-ComplianceNo. D'�—YHEALTH DEPT.
COMAM-Ng�) 14USETTS
Board of Health,
MA.
FEE
�; ea-�, I � 5q-,:e�
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System ❑ Individual Components
Location 16
COn.aeavati,on V,%tve, yawouth vtt
Owner's Name Ed youn
Map/Parcel#
Address Same
Lot#
Telephone# (50$) 375-0935
Installer's Name
Nonthenn Pavj-n_q, Ray Catera f no
Designer's Name Scho j-e2d 13,'[0,5 .
Address BOX
995, Denn-i,6pont MA 02639
Address Box 101, 0,c2eanz MA
Telephone#
50$ 39$-9474
Telephone# (50g) 255_209g
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
No. of persons
Lot Size sq. ft.
Garbage grinder N/A
Showers ( ), Cafeteria ( )
110 gpd Calculated design flow :330 Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -�, A' St a S C-4-- ?"A -4 c
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t not tp lace a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r Date - 2112103
Inspections
COMMONWEALTH OF MASSACHUSETTS FEE
Board of Health, Yvcrnauth , MA. e l
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (X), Abandoned ( )
by iWo)tthlean'._3•eatcoai i vt,g 9 Pav i vrg . inc., Ray,-CateAtno.
at 16 ConAma-tion Pti.ve, Yanmouthpott
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. O '? ` � , dated 2.--'2* 03. Approved Design Flow' gpd)
Installer Kay Cate4ino, Nojtthonn Pavinq to
Designer: Scho 4ie•2d Moz . Inspector: Date: f
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. Com' �;3 - � � / Cf �� I �-/�•� �/ r v ��� FEE
C'®MMONWEALT14 Of MASSAC14USETTS
Board of Health, Yanmouth , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (X) Abandon( ) an individual sewage disposal system
at 16 COnzeavati.on V,%i.ve, yaxmouthpott as described in the application for
Disposal System Construction Permit No. 0 dated 2-2 Z7
Provided: Construction shall be completed within s of the date of this r it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date.2 Board of Health