HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT, f/
1146 ROUTE 28 FEE
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Board of Health, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
lication for Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System e1ndividual Components
Location ��fif%(` grjpGX
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Owner's Name �/� /(
Map/Parcel# jV t4 4or OLa
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Address % � jQr%f
Lot#
Telephone# ,SO?' - 3 `ol 3 5 f 6
Installer's Name ,vC (7
Designer's Name
Address 3 ,s o 1�,,.v®,v s.,r
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Address
Telephone# 5-&4r ?, r - i'ap
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title,
Description of Soil(s)
Soil Evaluator Form No.
a JS E
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS IV%4//% ''I I'V F 16149 pJE jo B ,0L
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre o not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. p ¶�' FEE
COMMONWEALTH
H Opt" MASSAC14US ETTS
Board of Health, vette L172!�` , MA.
CERTIFICATE OF COMPLIANCE
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Description of Work: $(Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired X, Upgraded ( ), Abandoned
by: od—� tirp s'G !�'�/.tom T Z,
at t f/,�AT
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. - , dated 7 Approved Design Flow (gpd)
Installer t
Designer: Inspector: