HomeMy WebLinkAboutApp-Permit-Complianceil YARMOUTH HEALTH DEPT. 5-b
No.
FEE
1146 ROUTE 28 r
®MM®NV)T"�,MAs9�TIlUSETTS
I�i'�-T ��zi' G
y Board of Health, _Tfi /�M'MA.
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 5F4'
Owner's Name
Map/Parcel#
Address
Lot#— ��
Telephone#
Installer's Name 6!520/ y+ 1
Designer's Name
Address IT�� Z
ddress
Telephone#`? 6- '. �jZ
Telephone#
Type of Building Lot Size i �1 %�V sq. ft.
Dwelling - No. of Bedrooms Garbage grinder �jfi 5
Other - Type of Building No. of persons Showers Pl�—Eafeteria ( )
Other Fixtures
Design Flow (min. required)
j�J gpd Calculated design flow Design flow provided gpd
Plan: Date -'-/�— f / Number of sheets / Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Date of Evaluation T
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nat4irplace the system mi peration until a Certificate of Compliance has been issued by the Board of Health.
Signed /�����Date
Inspections
No. SC®MMONWEALTH OF MASSACHUSETTS FEE
j
Board of Health, " a k" , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) -' , Complete System �G
The undersigned hereby certify thaL the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned
by:
i
at r ',...,:- f.� ,°c'�'/ l''✓'� - iL� t`1 Z% d91Z- 1J [s is .
has been installed iy" accor�n e with the pr 'sion of 3 0 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No. Q " dated % � Approved Design Flow =� (gpd)
y
Installer f . s' -S . L-= A? '5
Designer: Inspector: Date: 1
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. r ` FEE-
C®MMONWEALT14 OF MASSAC14USETTS ii e4 %/ro �
4-4
Board of Health, �� JL %ij AA - Y MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon(
i �N,
?/9 .�'!LG'. 1 rlr4 � /� . 0 40/'1!
Disposal System Construction Permit No. dated
an individual sewage disposal system
_ 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 11 Board of Health