HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No.i 6 1146 ROUTE 28
SO. YARMOUTH, MA 02664
SaIL n�moyfiL�
_ r/l f �3 Board of Health, � R CZYh o Ml , MA.
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(,/) Abandon- Complete System U Individual Components
Location 4-7 vll l LL lzoack
Owner's Name N)4p 'e , CA4vi9 v► e
Address 4-7 W 12om A QJ, YA V -m `
Map/Parcel# ?- j - ij6 (oL,p Yvi S
Lot# L o -t- 4j
Telephone# -771-3(.5(
Installer's Name L
hi
Designer's Name CA- p M -L A-c�
o s
Address
Address
Telephone#
Telephone# -7-75—'LI-700
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
9
No. of persons
Lot Size sq. ft.
Garbage grinder (PO
Showers ( ), Cafeteria ( )
Design Flow (min. required))33o gpd Calculated design flow 3l 3 Design flow provided 313 gpd
Plan: Date 4nn2-:5106 Number of sheets I /, /R•e,,vision Date n ,
Title ITL- IJf� Fo,- MAro C CA,oA�dP� Ln`�' 4-1 Uj,(Il&nA- A d, Uj- m• h
De3cripdon of Soil(s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS OR ALTERATIONS
11 TU 6A 1f z. S.. /-/1- N, n Q 4?,3 10
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further Vtnogt a the tem ' operation until a Certificate o mA
ce_ yes been issued by the Board of Health.
Signed Date �,147�
m
Inspections
No. '. FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, yF1i Z- m o v �-} MA.� !�(
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CERTIFICATE Of COMPLIANCE
Description of Work: U Individual Component(s) U Complete System -
`The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned I/J
by: �f ^� l��LW/1
at ( � I� 1A-yv) C PO1;-- i I1 J. RP-mUUT1
has been installed /
iin ccorda
ce with the provisions of 310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. I� J- dated 6' e . Approved Design Flow .-3 (gpd)
Installer //
Designer: ALf> -Jt*`0'101t/4( I/I<-- Inspector:
The issuance of this permit shall not be construed as a guarantee that the
No. (j
Date:
will function as designed.
, 0 _ FEE -
COMMON*E-ALTfl Of MASSACHUSETTS
Board of Health, MA.
V0)AL ;�) ]C hffl k -UA 31JKUJ -11UA IrtlKPY111
Permission is hereby granted to; Construct( Repair( ) Upgrade (4 Abandon (4an individual sewage disposal system...
at -4-7 W l LL) R-Yvt S So( - t 1 (J • �I R IZrrin 0-1 -H 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 per 't. All l cal conditions mijst be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date yU Board of HealthL�`