HomeMy WebLinkAboutApp-Permit-ComplianceNo. _!-P FEE
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�/ � Board of Health, DWT. YARMOUTH HEALTH DEPpT. v
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APPLICATION FOP, DISP09AYAWWKWONMUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeOe)/Abandon( ) - ❑ Complete System L/'lndividual Components
Location
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Owner's Name Joh
Map/Parcel#
, ���ri
�A
Address
Lot#
5 /Si "b
Ab
Telephone#
Installer's Name
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Designer's Name
AddressSIS$
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-rW411,
Address
Telephone#
171 —
Telephone#
Type of Building �,s>D�r Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder44/0
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min.
Plan: Date
Title /5
Description of Soil(s)
Soil Evaluator Form No.
&e- gpd Calculated design flow 330 Design flow provided 3 5-X6- d
9/ Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS z , e .-z�;;7 Gt.0 o2P
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 t of to p e s3iFtem in operation until a Certificate of Co plianc has been issued by the Board of Health.
Signed Date 0
a Inspections 7~ '-O Com/ O'er_ - D�I.f $ls��/�21 C�.P,Cb_ �� 0 y
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No.
No. Cf r ~ ' 3 FEE -72) TZ
t Board of Health,MA
CERTIFICATE Of COMPLIANCE,...
Description of'Work: 0 Individual Component(s) ❑ Complete System
The undersigned hereby certify thaflthe Sewage Disposal System; Constructed ( ), Repaired ( ),,Upgraded (✓j' k ndoned ( )
at
has been installed rrinac orda?ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. G��` �� dated 7t/ DI . Approved Design Flow
Installer -d G y`%
Designer: �.fi'�^% �`? Inspector: Date:y
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. J
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No. // �% S� - -- - d ry4i 'UG , FEE �� r
COMMONWEALTH OF MASSACHUSETTS SCG � 17�6,/
1 471,OW4 ern.
Board of Health, ,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade (Vf-.'Abandon ( ) an individual sewage disposal system
at 1� ��iK- �i ias described in the application for
Disposal System Construction Permit No. I ' ��(� dated
Provided: Construction shall be completed within-ts f th'e date of this permit. All local conditions must be met.
Formm/, 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 7 f ?r �� Board of Health ZA/