HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. S; 1146 ROUTE 28. FEE
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSAC14USETTS
�lLs C
Board of Health,�T , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeC j' Abandon( )„/EPComplete System ❑ Individual Components
Location
/-aOwner's
Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name _./
` ,r— cc -o
Designer's Name k' -"pp -
Address[
kr 1A icl'2
Address 5 7 / i h lwc
Telephone#Telephone#
. (43d
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 1�e Design flow provided gPd
Plan: Date S&L& i Number of sheets Revision.Date
Title
Description of Soil(s) SP - La V
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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
Inspections
FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, Am. A�5—j,�v
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) egWomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. —� dated - Approved Design Flow'¢ ? gpd)
Installer FL L / S t%2lJS _ e
Designer: Aflof 1p! -M l) / /t Inspector:
The issuance of this permit shall not be construed as a guarantee that
No.
Date: 7
t16 system will function as designed.
Z-/ FEE
COMMONWEALT14 Of MASSACHUSETTS role -1 1-4
Board of Health, �-' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( ) UpgradeA , Abandon ( ) an individual sewage disposal system
atS/r� as described in the application for
Disposal System Construction Permit No3 9 .2S ,dated �o —'/(%
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 /V/ ^ ',�%oard of Health