HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. - • 1146 ROUTE 26 FEE
COMMONIffAW ?M' MMUSETTS
Board of Health, MA. "
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 6 GressOwner's
Name (�" / Oro -,0 �
Map/Parcel# 33 S
Add -0 41066,(V L Tlf
Lot#
Telephone# L10-0 r
Installer's Name // 1 �
Designer's Name ib-T✓y y
Address t9 /,4Fry-
Address S'' 2C4 .L,,
Telephone# 3 6- to
Telephone# SO -- —9,/-7--7
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
Garbage grinder (*10
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 30 D( i. gpd Calculated design flow X0&0 Design flow provided ��66 gpd
Plan: Date 7 10/�fd)� Number of sheets l Revision Date d
Title
Description of Soil(s),.'
Soil Evaluator Form No.
of Soil Evaluator
DESCRIPTION OF REPAIRS ORALTERATIONS -C it
Date of Evaluation
The undersigned agree install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to a the til a Certificate of Com fiance h been issued by the Board of Health.
Signed Date c.r •�'�
Inspections
No. COMMONWEALTH Of MASSAC14USETTS FEE
Board of Health, ; ,/ 4 i ��l c "T J-2, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) elB Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: Co / G /l 9 i -C6h5
at SO �'l G 66,-, L--,7 - -
has been installed in accorda ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated /d —23 –'?,+ Approved Design Flow '� (gpd)
Installer i-1 / f S 4 d G T'�,P<.5 c -,? ,S'A , .,
Designer: ()'i v ,' b ��'il SG'9 Inspector Date: _
The issuance of this permit shall not be construed as a guarantee tha the system will function as designed.
No. � — -
fS r�
COMMONWEALTH Of MASSAC14USETIS
Board of Health, � C, r �`� �` MA.
� v DISPOSAL. SYSTEM CONSTRUCTION PERMIT
/1"1i` 17r/-,
FEE
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at ;:s % C &JI%lj+ -� ��l'i '` ' 6V el e - as described in the application for
v
Disposal System Construction Permit No. G% dated / `.c
Provided: Construction shall be completed within thrrjee 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 /(}"I� – 7 Board of Health , /