HomeMy WebLinkAboutApp-Permit-Compliancet
• r �/tom(
No. �'/ FEE GV, do
COMMONWEALTH OT MASS CH ATTS
YARMOUTH HEALTH DE
Board of Health,, 4 46 RO UTE 28 - , MA.
APPLICATION FOP, DISPfflArTRYNITMMUCTION PERMIT
Application for a Permit to Construct( ) Repair ('Upgrade( ) Abandon( ) - ❑ Complete System C-hl�"dn ividual Components
Location 0-1
s
Owner's Name
Map/Parcel#
U Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address
Address
Telephone#
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.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
r
DESCRIPTION OF REPAIRS OR ALTERATIONS
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a s to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
SignedZ4 _7Q2"e_49fDate
Al—z-
Description of Work: 0 -Individual Component(s) ❑ Complete System.
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (v) -Upgraded ( ), Abandoned
by:
at
has been installed in ccordan/e with the rovisi ` s of 0 CMR 15.00 (TitlX and the approved design plans/as-built plans relating to
application No. =�-�! dated ^' Approved Design Flow (gpd)
Installer
Date: k�`rz7VY
Designer: """"'"" Inspector:
The issuance of this permit shall not be construed as a- guar ,, that the system will function as designed.
No. ! Cs"d i ✓(/r - FEE '7U, C/C/
COMMONWEALTH OF MASSAC14US ETTS
Board of Health,. f: MA
DISPOSAL WSW< CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(' ) Repair(,,'Y' Upgrade,( :) Abandon( ) an individual sewage disposal system
at / �-1,11 /r a as described in the application for
Disposal System Construction Permit No. L4/'dated''�'��7'�.
Provided: Construction shall be completed within G% of the date of this p it. All local conditions must be met.
i
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ( f ~!/� Board of Heth
al