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HomeMy WebLinkAboutApp-Permit-ComplianceNo. � � /,�y .Ji AnImalm 4�6Av" � FEE 0'. r C/C/ Board of Health, 1146 ROUTE 28 50. YARMOUTH, 02664 APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( - ❑ Complete System M Individual Components Location zq �% e� �� a %�' Owner's Name /i�% %t/ Map/Parcel# 115— 5— Address Lot# Telephone# Installer's Name © 7P ® ) Designer's Name i Address �`- Address Telephone# 7 1— Telephone# J� Type of Building Dwelling - No. of Bedrooms Other - Type of Building 11011c tf No. of persons Lot Size sq. ft. Garbage grinder (L% Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. req fired) gpd Calculated design flow Design flow provided � gpd Plan: Date 2;; M Number of sheets , Revision Date Title J` 1.5/ 7` Description of Soil(s) Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator 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 agrees ton to lac the em in operaq�t until a Certificate ofCo lian •e has been issued by the Board of Health. Signed Date 2 Inspections No. �6 �G.— � �� FEE COMMONWEALTH Of MASSAE USS S Board of Health, �� U %� �/ , MA. 1 CERTIFICATE Of COMPLIANCE Description of Work: U Individual Component(s) ❑ Complete System The undersi ed hereby cf rtify that the, Sewage Disposal System; Constructed ( ), Repaired M(Upgraded ( ), Abandoned ( ) by:O!`d p Lill , at 6 has been installed in accordance with the provisions o 310 CMR 15.00 (Title 5) and in proved design plans/as-built plans relating to application No. 1 ',,),.dated _ :�. iJ Approved Design/Flow �7` (gpd) Installer t�G"�./(� t/Y1(J�u Designer: Inspector: 61lu t Date: / OCI- The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No.Ui/ % l ' �✓i/ / FEE r C®MMONWEALT14®f MASSA 14US ETTS V� Board of Health, /����%_ MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby 1granted to; ConstructRepRep 'r( t.�Upgrade( ) Abandon( ) an individual sewage disposal system at V �`/'� !� / as described in the application for Disposal System Construction Permit No. t,469 dated (9 Provided: Construction shall be completed within rs of"�jthe date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -� Board of Health r t