HomeMy WebLinkAboutApp-Permit-ComplianceNo. V
D-8ox OAA47
1146 ROUTE 23
S4. YARMOUTH, MA 02664
C®MMONWF—A LT14®F MASSAC14USETTS
Board of Health,
MA.
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit oConstruct( Rep 'r Upgrade( ) Abandon() - Ll Complete System 16 Individual Components
Location
3/ £
Owner's Name
jiv 0/1F T/rA
Map/Parcel#
!
Address 3JT
��� ��rrx, So
Lot#
Telephone#
- jfS3
Installer's Name �(/ �` p
Designer's Name
Address
�S'p ��jti �� - t/
Address
Telephone#
Telephone#
Type of Building �t//�� f X Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
gpd Calculated design flow
Number of sheets
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
gpd
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS J X :Vic R f., -
The
-,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 place the syste m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ��- ` f
07
Inspections
No.—if�; 7 COMMONWEALTH OF MASSAC14USETTS FEE
Board of Health, . /y9T12 /7`7" , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(,) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired jk), Upgraded ( ), Abandoned ( )
by:� E d
at f,< 6 11C C+r''4' .5 7` .5
has been installed in accordance with the provisionsif 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatio o. date /�-Q_. Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. S-7 /f `L�/( FEE
COMMONWEALTH Of MASSAC14USETTS
f ahBoard of Health,✓ . MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair.(") Upgrade ( ) Abandon ( ) an individual sewage disposal system
at m t': /� F �'' , 4iW as described in the application for
Disposal System Construction Permit No. /, dated
\ Provided: Construction shall be completed within three years of the date of this permit. All to alconditions must bme met.
\ Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �!" �'"
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Form of Health
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