HomeMy WebLinkAboutApp-Permit-ComplianceNo. _an -_16 6
A�-�ZMMONWEALTII Of MASSACHUSETTS
G zJ71'y YARMOUTH HEALTH DEPT.
} Board of Health, 114§1 eUE2 MA.
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APPLICATION FOP, DISP09R-MM14 �MWUCTION PERMIT
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - 0 Complete System 0 Individual Components
Location Wp'e
Owner's Name V/ L
Map/Parcel# 0zp /S Z/3- /3
Address SArrIE
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Lot# S
Telephone#
Installer's NameR 13 , u Cc
Designer's Name
Address G �IIESTE�2 2 u,
Address 2 r'o CowjOWISS L4, f S -0-263
Telephone# 4,3Z- 6,S-3 O
I Telephone# 3 gs Z Z,_-5-_'
Type of Building �[tj�i /VG— Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (N/p
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 1530 gpd Calculated design flow -330 Design flow provided 33.2,•,Z) gpd
Plan: Date 3 - 9 O N ber of sheets Revision Date
Title
,PAAPt3SP.B SE PTic.1JEs/�1J
Description of Soil (s) _*Y1=_.F_ VL AI AI
Soil Evaluator Form No. ZQ 7 4— Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS /-iq / I E ,b S R S
of Evaluation 2,11ZL0l,
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 a the syste ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �( �� Date
Inspections
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Cl/ _ COMMONWEALTH OF MASSACHUSETTS
,. Board of Health, MA. i s (i�
CERTIFICATE OF COMPLIANCE ®� � �/off 6� 411
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Description of Work: 0 Individual Component(s) O'mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
by:
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hd b�j,,inst led iA1c7,A0c7,,th the p�visi s r 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. adated //��� '/ 77 Approved Design Flow ���. 2_(gpd)
Installer L
Designer: (,.Cj Inspector: C� Date:
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The issuance, of this permit shall not be construed as a guarantee that the system will function as designed.
No.� O C/ v/�� FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, /rlGeL1� NIA. '
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at `: I A r /C O 1' s /'% L A 2w' Alf "C&`nl as described in the application for
11
Disposal System Construction Permit No. Q 2 66 dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions mush e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 5 Board of Health �s
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