HomeMy WebLinkAboutApp-Permit-ComplianceNo. O
/7�a 4L--7- FEE ✓V, e
YARMOUTH HEALTH DEPT,
Board of Healthl 146 ROUTE 28 , MA.
APPLICATION FOP, DISPMATAMYN4"MUCTION PERMIT
Application for a Permit to Construct( ) Repair(,._,) Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location
_ t
Owner's Name
Map/Parcel#
Address e ' ',
Lot#
S7 S'
Telephone#
Installer's Name
Designer's Name
AddressR IW
S
Address WJ , 02331
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) `I'1-{'� gpd Calculated design flow 440 Design flow provided 45CI Q I gpd
Plan: Date IA -)!?—1 Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
5iOc
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to plade the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date j : .1(
i
Inspections
No. �� _ '! U FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health,MA.
CERTIFICATE _Of COMPLIANCE
Description of Work: 121 -Individual Component(s) ❑ Complete Sysiem
The undersigned hereby certify that the Swage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at 1!5 LrFUC EC—,'S WA\j • YQ
has been installed in accordance with the provisions --of�f 310 CMR 15.00 (Title 5) and the ved design plans/as-built plans relating to
application No. �% ` i�� dated, ln� `IO (J �. Approved Design Flow "�pd)
Installer F R 1C�H �` it v `- ii d-, T inm (t-) . Z , A
Designer: ��.�1 (�� � hCG Inspector- 66&Vy Date: AT
The issuance of this permit shall not be construed as a guarantee that tb1system will function as designed.
— r
No. t/ / -� % / /7 - FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, b [ t , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( �), Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 115.� .�,� �J ` Q 1� ��MU)p
1 i [ ► i � / as described in the application for
Disposal System Construction Permit No. Q/-- �/ Udated
Provided: Construction shall be completed within tllxa 1 e' date of this permit. All local conditions m - t be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date V Board of Health
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