HomeMy WebLinkAboutApp-Permit-ComplianceNo. I FEE I
COMMONWEALTH OF MASSACHUSETTS
YARMOUTH HEALTH DEPT.
Board of Health, 1146 ROi�T€ 28
APPLICATION FOR OISPOM' nTRKT, M91MCTION PERMIT
Application for a Permit to Construct( ) Repair (vy'*Upgrade( ) Abandon( ) - (Complete System ❑ Individual Components
Location
Map/Parcel#
Owner's Name
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address (
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow S� Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
. , D"'escription of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
of Evaluation
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 the system in operation until a rtificate ofompliance has been issued by the Board of Health.
Signed Date
Inspections 5iLS
6 �
COMMONWEALTH Off' MASSACHUSETTS
tV- o1��G oy
Board of Health, MA.
C E RT I F I C Ad 0--F C M mm ��TT
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ) , Repaired 4or Upgraded ( ) , Abandoned
by: 4u A C B vc `�Y1 �t 4 s go( 4,8-A 77,e
at P--:i�h , et s ,! : <�a
has been installed in accordancg with the provisions of 310 CMII(iI5.00 (Title 5) and the approved design plans/as-built plans relating to
application No.
- dated 6 - Approved Design Flow (gpd)
Installer o_.r u�! � �-��I �. ✓ A � <
Designer:
The issuance of this p rmit sh
No. C �i FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, if MA.
DISPOSAL SYS C WI TRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(&,)- Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No.
as described in the application for
Provided: Construction shall be completed within tbAd(G atm" o�the date of this pe mit. All local condid s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health /