HomeMy WebLinkAboutApp-Permit-ComplianceCO MONWEALT14 OF MASSACHUSETTS
Board of Health,
YARMOUTH HEALTH, 9AMA.� T.
1146 ROUTE 28
APPLICATION FOR DISPOS T- MfCMN9 CTION P ERMI]
FEE
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location kp1.b L-wn
&44, Q. pf.�
Owner's Name *4 Qjp AS
Map/Parcel# St' —$$
Address D 4,p T b,44, K�—.
Lot#
Telephone#
Installer's Name
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Designer's Name
Address 1
��D
Address
Telephone# Qg, lie
–
Telephone#
Type of Building S ►/,, S�� T+®�(�''� �2 Lot Size $ b o3 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 ?110 gpd Calculated design flow 1436
Plan: Date Number of sheets IP -
Design flow provided ?ab gpd
Revision Date
Title �
Description of Soil(s) c�" 4 Qr4
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS T\ --,Ct. �p*1E� CkSS `w�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further gree of p c s tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed /N Date
Inspections
No. COMMONWEALT14 Of MASSAC14US ETTS FEE
Board of Health, L I/ 7tz
, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑k.Complete System
The undersi ed hereby certify that the Sewage Disposal System; Constructed (�, Repaired ( ) , Upgraded ( ) , Abandoned ( )
by: (��,�erce� �Y, +; 6 r
at
h
rias been installed in accordance with the rovi11siAons of �j0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. � % dated -,)Q /. Approved Design Flow (gpd)
4 , t
Installer S O Q 07AY
Designer: L /T!�tmtjw---
The issuance of this permit sl
No.—�
Inspector:
Date: g /�
ill not be construed as a guarantee that the system will function as designed.
COMMONWEALTH LTH Of MASSAC14USETTS
Board of Health, X' P / YJ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE �`"
Permission is hereby granted to; Construct(- l) Repair(/) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 12 ,(
U c -0"c 1 o' �
k . N. as described in the application for
Disposal System Construction Permit No. 7 dated
Provided: Construction shall be completed within thxzE ea `of the date of this p , r it. All local con 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date o:� I -i% 7Board of Health