HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. / 1146 ROUTE 28 FEE ZJD
SO. YARMOUTH, MA 02604 kt�4
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location J ✓, Pe-.
Owner's Name ✓ , , �� �, ,,
Map/Parcel# 3,
Address
Lot# 37
Telephone#
Installer's Name ,,4 e-
Designer's Name C le- ,'viv�
Address /' -7-7 �✓ L ��
/
{,
Address r � r✓ r -T
Telephone#
�7 U v )
Telephone# S G11'
Type of Building A, "✓ -- Lot Size 9-7T 7 sq. ft.
Dwelling - No. of Bedrooms 'a~ Garbage grinder ( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ��i �% gpd Calculated design flow Design flow provided 41 gpd
Plan: Date Z 1✓' ' » Number of sheets Revision Date
Title �f'9! C �� IG""� V,—./: IS PI
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REP/AIRS OR ALTERATIONS �� Z z
J��/)L
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreeAto not t eace syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Szgned Date q-ZZ
Inspections
No. (Z� loll �r��]� �~ (���(� T
C® O V'V' �C�ALT14 O MASSAl.�tJtl SETTS
Board of Health, 7 ( ( (Y1S6 t r jj MA.
CERTIFICATE OF COMPLIANCE
FEE G
i
Description of Work: ❑ Individual Component(s) ❑ Complete System //
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired )6 Upgraded ( ), Abandoned ( )
by: j�l I �t b C G �
at lli Ct1t�1CC� T) C?
«`` � (
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and tl�e p roved design plans/as-built plans relating to
application No. dated _ Approved Design Flow (gpd)
Installer
Designer:( - -AC-( Inspector: e���LLl�/ (( /.�.�sl ��C Date:
The issuance of this permit shall not be construed as a guarantee` that the system will function as designed.
No.
Board of Health, 1� AR M 6-( MA , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted two; Construct( ) Repair �) Upgrade( ) Abandon( ) an individual sewage disposal system
at 41 S t m S E-.% tJ [ Q (:F as described in the application for
Disposal System Construction 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 _f_ Board of Health