HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH Of MASSAC14USETTS
YARMOUTH HEALTH DF,,pT.
Board of Health, 1144ROUTc est MA.
-/ dcompleteSystem
6 I osApplication for a Permit to Construct(r) Repair( ) Upgrade( ) Abandon( ) - ❑ Individual Components
Location 9'D /11,6 /f,A4.M
Owner's Name .i A /CD/e {, Ajr--1e v
Map/Parcel# /SO el
Address PB. Ro,C /.2/D (o. ! .7 -if
Lot# IV /
Telephone# .SOd. 737. Y,70 `7
Installer's Name l44/7�i�.)
Designer's Name 4gfG. 4 u
Address P D. (3♦ 3e /� /D trp. �vi�v/«�h
Address �S% Rs 'fe lop W —rj
Telephone# 6'O P- 39Y sos/
Telephone# SOf % 77F. F9/ j
Type of Building KIS;o(em b 11,0sn G Lot Size .3. S6 ACets _
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons J4- Showers (+4, Cafeteria ( )
Other Fixtures S-+0We"O 5 -,,kr 5r0i'%tow�
Design Flow (min. required) 7'70 gpd Calculated design flow 7x 110 606 = Design flow provided 770 gpd
Plan: Date 71 2-710Y Number of sheets q Revision Date 7127 �0
Title &or j���i�o lG I S7 t 03
Description of Soil (s) LDA /4 Y SAND
Soil Evaluator Form No. F/ 7 3 - St P. D w 6- Name of Soil Evaluator M' P 6 t R 1'14 Date of Evaluation cf j/ F OD
DESCRIPTION OF REPAIRS OR ALTERATIONS !ev/�
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 to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �� / Date 911-14 /O y
Inspections ,fC /a .] SG4S Z
No.
Description of Work:
The undersigned hei
by: vii"
at t&) AG
FEE
COMMONW-EALT14 Of MASSACHUSETTS
VV//�- 0, 3
Board of Health,a,07G1F/ 117 MA. t
CERTIFICATE OF COMPLIANCEA
❑ Individual Component(s)omplete System
>y certify that the Sewage Disposal System; ConstructedY�, Repaired ( ), Upgraded ( ), Abandoned ( )
/ - /.^ - _ n % _.
has been installed in c
application No.
Installer
ins of 10 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
.
Approved Design Flow � ;7 (gpd)
Designer: (��� a UYInspector: VZ) 4' I Date: U J
The issuance of this permit shall not be construed as a guarantee that the system will function as desighed.
1
No.G"/ FEE Az
COMMONWEALTH Of MASSAC14USETTS
Board of Health,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
r
Permission is hereby granted to; Construct' ) Repair( ) Upgrade t ) Abandon( ) an individual sewage disposal system
at `�G' / �% !/P/ as described in the application for
Disposal System Construction Permit No. ~ "/.' dated hf 1-17
Provided: Construction shall be completed within trs of the date of this pe it. All local conditions must be met.
as //
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat/c� 4 !/moi' Board -of health CA t