HomeMy WebLinkAboutApp-Permit-ComplianceNo. O/ �J FE *&&'
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Board of Health, 1146 ROUTE 28 , MA.
APPLICATION FOR DISP® 1M?fflM19VUCTI®N PERMIT
Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 315 Winslow Gray Rd.,wYarmouth
Owner's Name Frank Freeman
Map/Parcel#�-J
Address
Lot#
Telephone#
Installer's NameWm. E. Robinson Septic Ser.
Designer's Name
Address P O Box 1089, Centerville
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
r
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS n Pw R 20 D- h ox
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
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 ce a system operation until a Certificate of Compliance has been issued by the Board of Health.
Signed c Date —i
Inspections
No. D/ T5 2-- FEE
COMMONWEALTH I� LTH ®F MASSACHUSETTS
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/140
Freeman
Board of Health, yarmailth MA. ,7
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CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( )
by: Wm_ E. Robinson Septic Service
at 315 i+ i s 1nw Gr . , wyarineut ?
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. t11- "; .3 z, -dated �� v��- ��. Approved Design Flow - (gpd)
Installer
Designer: Inspector: tff� Date:
The issuance of this permit shall not be construed as a guarantee tha the system will function as designed.
No. ��— - �%y (/ FEE '.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, Yarmouth ; meq,
Freeman DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Y Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 315 Winslow Gray Rd. ,IiYarmouth as described in the application for
Disposal System Construction Permit No. D�" 3z. dated
Provided: Construction shall be completed within thus
of -the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date LLaL-0-1— Board of Health
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