HomeMy WebLinkAboutApp-Permit-ComplianceNo. go f FEE
COMMONWEALTH OF MASSACHUSETTS —10 —[2
Board of Health, YARMOUTH HEALTH DEPT.
1146 ROUTE 28
APPLICATION FOR DISPOSAD-W§RWr6,WX9iRWTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade X Abandon( Complete System U Individual Components
Location 2f
jwL% 5 4/t/
Owner's Name
KAIM MA9W
Map/Parcel#
4610 �
Address G�
Lot#
8
Telephone#
Installer's Name G -6_ CdW5V/•-v�GV INC—
Designer's Name
Address
. l aAy®j A 001---x103Address
n�e,/�j
A1773 Betk,57M /i✓4_
Telephone#
�� -1�`% 5 wjwl
Telephone#
SO -YM- Z j/ 6
Type of Building R65091lL-67 Lot Size n z -v3 sq. f
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) T90 gpd Calculated design flow
Plan: Date /0 -Z3- 01 Number of sheets 1
Title $EWA 16C M.5 65A -L- 5Y5Z-M PPd dt d
Description of Soil(s) _
Soil Evaluator Form No.
,44, /4,41
�•,l'F $qTJ/�
Design flow provided gpd
Revision Date Al h
Name of Soil Evaluator AAty YVI &j5d*C Date of Evaluation V - d
DESCRIPTION OF REPAIRS OR ALTERATIONS �y 7-,"
The undersigned agrees to ' ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthers to not to I e e em in operation until a Certificate of Compliance has been issued by the Board of Health.
SignedVDate 11 Z.• 07
Inspections
No. "/ V t77 FEE $55-oo
Board of Health, VA�LhooTii , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: U Individual Component(s) U Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired () U rade (), Abandoned ( )
by: C C C a/V 5 MQC.7-�,oN
at -2q S A t_TZyy etS LA
has been installed in accordance with the rov7sio-is of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. X40 , dated - 0 7 . Approved Design Flov� (gpd)
Installer ' C. CoN5-rj .0 ow�j ,h -
Designer: C / _1. f r''Q IL Inspector: Date:
The issuance of this permit shall not be construed as a guarrantee at the system will function as designed.
No. V . C . CO Aj 5T)L U Gi% OM
COMMONWEALTH Of MASSACHUSETTS
Board of Health, rA-/ M 0 L)T-W , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
�,"JO
FEE
? K f) -4, 5 I -q �/f
Permission is hereby granted to; Construct( ) Repair( ) ra ( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. ��� , dated
Provided: Construction shall be completed withiil&� of the date of this pit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown. MA DateBoard of Health