HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. — 33 1146 ROUTE 28
SO. YARMOUTH, MA 02664
COMMONWEALTH. Of MASSAC14USETTS
Board of Health,
MA.
FEE
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(,� /Upgrade( ) Abandon( ) - ;2�omplete System ❑ Individual Components
Location,=K5
'Wrr
Owner's Name y
Map/Parcel#
A4� -
Address S
Lot#
1
Telephone#
Installer's Name
tG� S
Designer's Name
t e
Address
( v S;
`
Address
e
Telephone#?
r—O (C;
Telephone# 7—
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)) 3
1 3a
Plan: Date `C6
Title ,
Description of Soil(s) _
Soil Evaluator Form No.
i�rr]
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow Design flow provided
Number of sheets I %"�Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Date of Evaluation
gpd
The undersigned agrees to install the ibove describedjv#vidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthertem in o o til a Certificate of Compliance has been issued by the Board of Health.
SignedattZP!t, Date
v �
Inspections
No.
FEE
'L_.OMMONV'V' EALT14 Of MASSACHUSETTS
Board of Health,PIr � / ZftO' MA.
V
�-` 1
CERTIFICATE OF COMPLIANCE
1
Description of Work: 0 Individual Component(s) .S,Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: o& F_ ,c:
at
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. -, :3, dated t ^� - Approved Design Flow _3!!63_q (gpd)
Installer
Designer: O.iO�t Z466ti?" Inspector: 'Date:
^ �'
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No.
FEE �• C/L/
COMMONWEAll,T14 OfMASSAC1Jti SETTS
Board of Health, �1/L✓YJJI?�%il , MA.
DISPOSAI..SYSTF`M CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(
pgrade ( ) Abandon( ) an individual sewage disposal system
at M,,-- v as described in the application for
Disposal System Construction Permit No. iy-_J dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date re / 7hoard of Health