HomeMy WebLinkAboutApp-Permit-Compliancer No. 09- FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health,
.. •�• C HEALTH
APPLICATION FOR DISPOSOAG C®I'SPREf�fION PERMIT
SO. YARMOUTH, MA 02W4
Application for a Permit to Construct( (a Repair( ) Upgrade( ) Abandon( ) - °°Complete System ❑ Individual Components
Location �Ic���(j-�I�i �,
Owner's Name �� (� 0 1V-
Map/Parcel# WL
Address
Lot#
Telephone#
Installer's Name (2b W -F C41 LDg
Designer's Name QVL� K CAPG
Address f (0 01 ice► g 6TtqtA S. D (N W IS
Address Q.39 9 W l N Sj
Telephone# f 3'18-2-5S&
i Telephone# iJoa 3&a
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided ✓ d gpd
Plan: Date 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
The undersigned agrees to inst4n the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ce system in operation until a Certificate of Compliance
-has been issued by the Board of Health.
F
Signed Date
Inspections
No. O c , -7---,P� COMMONWEALTH Of MASSAC14USETTS FEE 1a
Board of Health
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersi need hereby /certify that.the Sewage Disposal System; Constructed Y" Repaired ( ), Upgraded ( ), Abandoned ( )
by: gp � i l L- LG! �5
has been mstalledVtLccolrace with t ovisio of 310 CMR 15.00 (Title 5) and the r proved design plans/as-built plans relating to
application No.� dated � � Approved Design Flow v (gpd)
Installer
' (` 1
DesignDae: a �Q
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
No. � �
lap"/ C lK CGS ` A/ �. FEE
Permission is hereby grant(
at .2-:3('Cdr%
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 141�"
DISPOSAL SYSTEM CONSTRUCTION PERMIT
to; Construct( Repair( ) Upgrade ( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. C.� "' _ , dated 7—
Provided: Construction shall be completed withirr-tk•� � the date of this rmit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date —� Board of Health