HomeMy WebLinkAboutApp-Permit-ComplianceNo. —Z6 2 YARMOUTH HEALTH DEPT.
1146 ROPTE 28 64
I �"TNTS!,IUSETTS,9&,4,7;t /A,610'2-!ZrCOMMONi�-*
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P t— Board of Health, MA.
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APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name ddl4fiS6311
Map/Parcel#
7/ �®
Address
Lot#
!L2Z7Z C
Telephone# c
Installer's Name
Designer's Name
Address
350 Maid Street
Address
Telephone#
W. Yarmouth, MA 02673
' Telephone# - a
Type of Building ALG.T . Lot Size sq. ft.
Dwelling - No. of Bedrooms 350 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 V gpd Calculated design flow
Plan
Title
Design flow provided -335 / gpd
Revision Jute .3 `
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS �I?
Date of Evaluation
;rhe 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 ja the em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 1 Date 3 -% ' O6
Inspections 3 - ed 4-C12) ,7i i doL .
No. 0 r/(- Z—
COMMONWEALT14 OF MASSAC14USETTS
Board of Health, �/%11�t - %/7 MA.
CERTIFICA� ALS � �
FEE J
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Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (graded ( ), Abandoned ( )
by: e"g,-7C'-
at
has been installed
� yii�-n����accordane with the provisions o���f��3771��0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 6Z)—Zj` �, dated 7 "yU Approved Design Flow (gpd)
Installer
Designer:JC— Inspector: Date:
— --
The issuance of this permit shall not be construed as a Lruldrantee tha the.system will.function as designed. ,
No.Z-- t (L FEE
COMMONWEALTH OF MSSAC14 SETTS
Board of Health, MA.
DISPOSAL SYSTEM &NSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( 4-1:5p�grade ( ) Abandon ( ) an individual sewage disposal system
atas described in the application for
Disposal System Con truction Permit No. / �,, 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 '/'%
oard of Health
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