HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HLALl M vr—r I .
No. ' �O / xe 1 146 ROUTE 28 �5�—"� FEE 57
SO. YARMOUTH, MA 02664
Board of Health, , MA.
APPLICATION FOP, DISP®AL SYSTEM CONSTRUCTION PERMIT
Application for a P rmi� to Construct( ) Repair( ) Upgrade( ) Abandon( - ElComplete System LJIndividual Components
Location ��
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Owner's Name
Map/Parcel#
Addresses
bd
Lot# &-10
AICX_,)
Installer's Name
,T,f.�� �A j V—,
Designer's Name
Addresse5
J
address
Telephone#
Telephone#
Type of Building Lot Size 2�6 sq. ft.
Dwelling - No. of Bedrooms � Garbage grinder (7D
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow f Design flow provided gpd
Plan: Date Number of sheets Revision.Date
"title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil
•-DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
a
The undersigned agr s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t t 1 e the ste o r tion until a Certificate of Compliance has
been issued by the Board of Health.
Signed Date .6—
Inspections
N..77`69
COMMONWEALT14®F MASSAC14US ETTS
Board of Health, MA.
CERTI 'ICTE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
FEE
The undermined hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: z� d
at
has been installe accordance with the provisions of 31'6 CMR 15.00 (Title) and the approved design plans/as-built plans relating to
application No. - 6 , dated Z Approved Design Flow �:(gpd)
Installer G 1' S .
Designer: �C.(/E�� lL3'� Inspector: Date:
The,Usuancb -f_ this permftshallnot-be-construed>as a. guarantee:tha e_system-will-function-as.clesigned...
No. r
FEE f-� -i
COMMONWEALTH Of MASSACHUSETTS
LZ/ i Board of Health, , MA.
DISPOSAL S YSTC®NSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Aban�on ( ) an individual sewage disposal system
at
Disposal System Construction /ermit No. c��z> dated
as described in the application for
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
/1) Board of Health