HomeMy WebLinkAboutApp-Permit-ComplianceNo.o�L70 FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, YASTMOUTH,
1146 ROUTE 28
APPLICATION FOR DISPOSAt0SVRM-CH0KiWCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
164 d
Owner's Name ,�
Map/Parcel#
A,
Address
Lot#
Telephone# S6 - '36 2 - 04 3
Installer's Name
4. �'�
Designer's Name
AddressS`
�/ �Me
Address o' 3
Telephone#
Jr&j 7 7C . `
Telephone# SG q3 -
Type of Building _��6 &r' l Lot Size sq. ft.
Dwelling - No. of Bedrooms Vii! /lC Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 gpd Calculated design flow S 3� Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Sfee A49 Is Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS A-11 4etcl5hha cei.1240)-r
!4 .2B 1717,r 2 x jj(-e2ej Pr.. Lx YS__ . _ �y s-�t.�... r•
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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
i Inspections
No. -A .:V FEE
C®MMONWLA T14 OF MASSACHUSETTS
Board of Health, 411-7ev MA.
CERTIFICATE Of COMPLIANCE � ` ��' - 1' � ` �✓
Description of Work: ❑ Individual Component(s)omplete$ystem
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaire�Upgraded ( ),Abandoned( )
by; C, 1.
at. y 71"to
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. �� - %Q, dated %d -,Or Approved Design Flow 3 d) '3 ✓ Cir
Installer ie4C.
Designer: _n y �f �t;� ry �ti r�+r .: Ins
�pector: Date:
The issuance of this permit shall not be construed as a guarantee that the.system will function as designed.
No. . — -- FEE
COMMONWEALTH OF
MASSAC14USETTS /442-
Board 6fHealth, �u ✓ M ov
DISPOSAL. SYSTEM CONSTRUCTION PERMIT,
Permission is hereby granted to; 'Construct( ) Repair('\ --Upgrade( ) Abandon(. an individual sewage disposal' system
at Y. as :described in the application for
Disposal System Construction' Permit No. ' Z , dated
Provided: Construction shall be completed within t� f the date of this permit All local conditions must be met.
i
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �� 4/)Board of Health