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HomeMy WebLinkAboutApp-Permit-Compliance - Never InstalledNo. (V/~5/ 17 00 FEE 5Q /� /r���O�l[MONWEALH Off' I�' ASSAC14USETTS c(� jG 4iBoard o Health f ARMOUTH HEALTH DW. l� f 1 4 6 ROUTE 28 APPLICATION FOP, DISPOAly MN99MUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( �Abandon() - "--complete System ❑ Individual Components Location Owner's Name Map/Parcel# �, 3 Address 15� Lot# Telephone# Installer's Name Designer's Name Address Address Telephone# Telephone# •� Type of Building 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) .d3� gpd Calculated design flow s� Plan: Date Number of sheets Title Description of Soil(s) Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Design flow provided _'1� ( gpd Revision Date 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 agreeto of t ace the syste o ration until�a Certificate of Comp ianc has been issued by the Board of Health. Signed ( `L�� COAA -t Date Inspections F z V V No. ©/ ` CO MONWEALT14 Of MASSACHUSETTS FEE � Board of Health,'i_, MA. G J Ov C ERTIFICA Off' COMPLIANCE �C Description of Work: ❑ Individual Component(s) b'Complete System The under igned hereby certify the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (�andoned ( ) by: at has been installed in accord ce with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to application No. m da Approved Design Flow (gpd) Installer Designer: S( In pector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. d l Sys/,� FEE F ,rte COMMONWEALTH Of MASSAC14US ETTS Wlbw I Board of Health,06divd — MA. DISPOSAL SMSA CONSTRUCTION PERMIT Permission is hereby ra ted to; Cons uct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system at t as described in the application for Disposal System Construction Permit No. 6 ^ �_2, dated1 z-1 7—,0 f Provided: Construction shall be completed within t ' of the date of thispermit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date of Health x, L/ 77) , ,, / ; C")// /, _