HomeMy WebLinkAboutApp-Permit-ComplianceNo.COMMONWEALTH Of MASSACHUSETTS
FEE
110000
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Board of Health, ,4r17 -e J e,4(i MA. _6 S �
APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMI
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Application for a Permit to Construct( ) Repair( ) Upgraw Abandon( ) - ❑ Complete System ❑ Individual Components
Location
U�'74
Owner's Name r �S C,/
Map/Parcel# �3
l (,
Address 'SA"l
Lot#
Telephone#
Installer's Name
Designer's Name me !-nor-
Address
350 Main Street
Address
Telephone# W.Yarmouth,
MA U2673
Telephone# 3 6� - a a, c'�—
Type of Building 1�,) -- S Lot Size sq. ft. '
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required 3 3 CJ gpd Calculated design flow Design flow provided- gpd
Plan: Date 7 a Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS `-+Df- P 4 ZO
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 la e tVIF� em in operation until a Certificate of Complianc has been issued by the Board of Health.
Signed / C C6&cc- Date Fh
6
Inspections D '
J
No. dU :L.. / S it FEEy
COMMONWEALTH Of MASSACHUSETTS
Board of Health, /r"' r` o MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System S)Ohe 51G�-
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned
by:
at ("" C
has been installed i ac rdan�ce with the rovis s oj3 0 CMR 15.00 (Title 5) and thea oved design plans/as-built plans relating to
application No. 0� �� �, dated ��^v Approved Design Flow 3. app
Installer ;�F/k � D
Designer: 11PIH 1 �`�VZlo' Inspector: �� Date: 4f-. g/
The issuance of this permit shall not be construed as a guarante that the system will function as designed.
No. A6 FEE
C®MMONWEALT14 Of MASSAC14USETTS
Board of Health, ,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby/granted to; Construct( ) Repair( ) Upgrade,( Abandon(
at 7 �` Iy/` e"17
JJ
Disposal System Construction Permit No.
Provided: Construction shall be completed within t-1 z44
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date
dated 0 - A a6
DR L111
an individual sewage disposal syste
_ as described in the application for
�S
of the date of thisli�r fit, -,All local condidops must be met.
Board of Health