HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,61
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COMMONWFALT14 Of MASSAC14USETTS
YARMOUTH HEALTH DEPT.
Board of Health, 11 da, -.6 ROUTE 2 Na.
APPLICATION FOP DISC® *,�I!rWCIION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad andon( ) - Complete System ❑Individual Components
Location
S
Owner's Name'
Map/Parcel#/l
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AddressAAy
Lot#
2Z Z
Telephone#
Installer's Name
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Designer's Name
Address a 3
Address c'13
Telephone#Telephone#
Type of BuildingLot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
a Title
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
gpd Calculated design flow' Design flow provided gpd
of sheets
S,Q-e Sc, I [C-,
Name of Soil Evaluator
Revision Date
Date of Evaluation
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The undersigned agree o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o� ace the tem ' o r til a Certificate of Comp 'ance as
been issued by the Board of Health.
Signed Date _ 1
s
V
Inspections
No. OL COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
52
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 6-77— L l S —�
at 23 C-, l r,
has been installed in accorda ice with the provisionsyof 310 LMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
� O dated �` -�l ^G . Approved Design Flow
application No. 0 (gpd)
Installer 17 'CCI /-+9
' Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee tha the system will,.function as designed.
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COMMONWEALTH Of MASSAC14USETT
Board of Health,�: <j f _ :, MA
DISPOSAL, SYSTEM -CONSTRUCTION PERMIT
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Permission is hereby granted to; Construct( ) Repatr ( ) Upgrade ( ) Abandon ( ) an mdtvtd ` sewa e dis osal system
at as descred rn`the application for
Disposal System Construction Permit N -o-61-0 dated
Provided: Construction shall be completed within th�ee"years of t ie date"of this per it. All, local conditions ust be met.
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1255 Rev. 5/9p,:A.M. Sulkin Co -Boston, MA Date �l Board of Health
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