HomeMy WebLinkAboutApp-Permit-ComplianceNo.'s FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YARMOUTH HEALTH PERT.
1146 ROUTE 28
APPLICATION FOR DISPOWYMWAQW69RUCTION PERMIT
Application for a Permit to Construct( ) Repair M/Upgrade ( ) Abandon( ) - U Complete System �dividual Components
Location EM
Owner's Name teb 12•
Map/Parcel# 411
Address 23 1 FLOC -h 14
Lot# 1 630
Telephone# '7
Installer's Name
Designer's Name
Address Z�OtlAddress
Telephone# _
Telephone#
Type of Building ��' f -�Q, Lot Size + sq. ft.
Dwelling - No. of Bedrooms Garbage grinder MI6
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided gpd
Revision Date
Name of Soil Evaluator Date of Evaluation
14
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to not to place syst in op ration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
a. No. 3(� COMMONWEALTH EALTH ®F MASSAC14USETTS FEE
Board of Health, y C{ K m ( U � MA.
CERTIFICATE OF COMPLIANCE AS I� u
Description of Work: t Individual Component(s) U Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (/Repaired ( ), Upgraded ( ), Abandoned ( )
by: I _e_ --^ /
At
has been installed in accordance with thNJ
.sio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.T ' `�3 , dated•l Gb Approved Design Flow (gpd)
Installer � I Cl_ Y1 P �- r .) 6 7I -1k _ - 1
Designer: ""'Inspector:�� h,i {_ Date: _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Now 0 C
¶` FEE I'"
COMMONWEALT14 Of ( �T
TTS
Board of Health, i�fn 0.1,C �,Am.
DISPOSAL S ll STEM CONSTRUCTION
PERMIT
Permission is hereby granted to; Construct( ) Repairr 1b Upgrade( ) Abandon( ) an individual sewage disposal system
_ - i ,
at
as described in the application for
Disposal System Construction Permit No. C"�13o dated d" O
Provided: Construction shall be completed wi +i -trze years of the date of this p it. l local ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health