HomeMy WebLinkAboutApp-Permit-ComplianceL0 -�[�
No. FEE S
6011 /,-0 COMMONWFAIT14 Of MASSAC14USETTS
YARMOUTH HEALTH DEPT.
Board of Health, 1146 R01 ITF 98 , MA.
APPLICATION FOR DISPONITMAi'M9MUCTION PERMIT
Application for a Permit to Construct( ) Repair (v<Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location P-,
Named
hit k ckeudc6
Map/Parcel# 3 — ! 8 `I�� LJ
Address
Lot# -DLe 447.3 cu-�>
Telephone#
Installer's Name A& B �'iANCO
Designer's Name
*Wyt Cw
Address 350 Main Street
Telephone# .
Address
Telephone#
3
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow
Plan: Date Number of sheets j
Title ^I 1 �- Q S Si ltC'P h4 A.i
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Pe t � 1 HSC/
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided 337 gpd
Revision Date NA
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 to not o p the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date^off S� `` 00
Inspections
No.
l -df9FEE
S o
COMMONWEALTH Of MASSAC14USETTS Va cG f �J� L
Board of Health, �C W `b 1 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 0"Complete System
The undersigned hereb certify that the Sewage Disposal System; Constructed ( ), Repaired (/Upgraded ( ), Abandoned ( )
by: ✓=% 1-0 (� U
at 1) (r /-/ v r'1 ! W GC l w1
has been installed in acco e with the provisions of 310 CMR 15.00 (Title 5) an t e a proved design plans/as-built plans relating to
application No. a —4 , dated `d –�)- —672) . Approved Design Flow (gpd)
Installer (�/J`GVCU
Designer:
The;issuance of this,permit shall not
No. 00 – / ,?
Inspector:
;trued as a,gu antee ,
1e� Date:
system will function as designed.
Board of Health, YCfil n 1 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE J v
Permission is hereby
granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 3 CC -40 v 1 I . as described in the application for
Disposal System Construction Permit No. , dated AQ J-yU
-S
Provided: Construction shall be completed within thrFe7r=s�of the date of this permi All to �alconditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA ��Date �l% 76Board of Health
121 -)Il 7T / , '/��% t - -7— Sr// / / 9// L.`V Y7//] A