HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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FEE 90.—
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YARMOUTH HEALTH DEPT.
ai 46 ROUTE 28
/�� d �� Board of Health MA. �� 1,�
FOP, DISPMAtM49qNM"MUCTION PERMIT
A ._ if n f a er 1 to ons ( Repair( ) Upgrade( ) Abandon( ❑ Complete System ❑ Individual Components
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Location
Owner's Name �) p
Ch -j"- �
Map/Parcel#';
Address
S �.
Lot#
Telephone# E
Installer's Namer,.--j I I s 13 ra)-)4i' GCik7sv, Co
Designer's Name
Address J
Yc ��r
Address
ice,
Telephone#
Telephone# 3;
_ 3 e2 �--,
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 'J J
Plan: Date Zf`i f)
Title
F gpd Calculated design flow
Number of sheets
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Description of Soil(s) S'e'r Sb on
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation i
DESCRIPTION OF REPAIRS OR ALTERATIONS S�P �P
The undersigned agree o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton ace th syste peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections '�x��li{ V\Zv'^e,-rG
,, t z
st-
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Z,kjni T4'- ► G+-% , MA.
CERTIFICATE OF COMPLIANCE
FEE O
v1 77
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: F: 11 l3 r 07-ke r S Cc 11 S} - y�Z
at ! I i l r4 t- q ifs -e•<}` Sc" 1-11 --V� rA , 0-)
has been installed in acc Cance with tl�, provisions of 310 CMR 15.00 (Title 5) an the ap roved design plans/as-built plans relating to
application No. _ , dated — rQ Approved Design Flow (gpd)
Installer /_01's 6 DT /Le (S CGYI Cf 6 t
Designer:b�iriYs tor: i` J J Date:_
V _VV _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH Of MASSAC14USETTS
Board of Health, lylQ
ir�G ti , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ��) Upgrade( ) Abandon( ) an individual sewage disposal system
at 1 I N l ci r S fr�-� S cct i-:�i /�''`� `' G as described in the application for
Disposal System Construction Permit No. dated Z 6
..Provided: Construction shall be completed within thi����s-ef the date of this pe
rmi . All local conditions must be met.
Form/1%255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Da/t@-/— ! c Board of Health
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