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HomeMy WebLinkAboutApp-Permit-ComplianceFEE No. -1c�`�I �-f' 2r ✓t/ �/ COMMONWEALTH OF MASSACHUSETTS c� Board of Health, YARMOUTH I-tEALTWMPT. APPLICATION FOP, DISP®S QJXTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(�J/Abandon() Complete System ❑ Individual Components Location ��"��(% lH� Owner's Name Map/Parcel# 8 L Address Lot# y Telephone# Installer's Name ©/` l© � C'�� Designer's Name ���% (me 4Ly , Address 6 JC`-7:4*3 f / Address Telephone# 7 Telephone# 3 10IZ-- 415VI Type of Building ce Lot Size sq. ft. Dwelling - No. of Bedrooms 3 Garbage grinder Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. require) �6� gpd Calculated design flow 3.3 Plan: Date e,�,o Number o_f ss—heetss 7' Title '61`1,P 69 cS'I & AW Description of Soil(s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Design flow provided 33 / gpd Revision Date 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 agrees to not o p ce tin o eration until a Certificate of Copli a has been issued by the Board of Health. Signed Date Inspections N.. C/;/ COMMONWEALTH Of MASSACHUSETTS Board of Health, )—alto" , MA. Description of Work: The under�j.zned hex by: ,EJC// l a 4 at 76 5 E IV has been installed in a application No. Installer / FEE 0 lin - Vj CERTIFICATE OF COMPLIANCE ❑ Individual Component(s) ER/Complete System )y certify that%`he Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded 4,6, bandoned ( ) 7/-- %/ %&/ zxL a V with the p o visio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated /d �a Approved Design Flow and Designer: /7/�t%� /f7'� �rt�4`r�c%Inspector: _� {.� Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. ��� ��j2, rt� Q // FEE (J ( s COMMONWEALTH Of MASSACHUSETTS d�V4 0� Board of Health, Z,G? 1'f , MA. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) at Upgrade( y)`Abandon ( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit No. ��-, dated Provided: Construction shall be completed within des oithe date of this perm' All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date aZ 6V Board of Health