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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 17 tol FEE l COMMONWEALT14 OF MASSAC14USETTS to-/ YARMOUTH HEALTH DEPT. Board of Healtfl48Rn�F 28 MA. ou Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - ❑ Complete System 2<;_ividual Components Location Owner's Name Map/Parcel# Address Lot# 7 Telephone# Installer's Name Designer's Name Address Address Telephone# "_72f--,ObEf Telephone# -1?' 7f7— Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Design Flow (min. required) Plan: Date Title F >;5escription of Soil (s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided 3 s gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees stall a above ' ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and Farther a.aeeo la a th operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 10V Inspections No. ( 7� 'l.®Ml`"llONWEALT14 Of MASSACHUSETTS FEE 5-0. r / Board of Health, �i�%(/?%/ , MA. CERTIFICATE Of COMPLIANCE Description of Work: $Individual Component(s) ❑ Complete System The undersigned hereby certify that^ the Sewage Disposal System Constructed ( ), Repaired Upgraded, ( ), Abandoned ( by: at has been installed in accordance with the pro, application No. % dated Installer l%%/j C✓%/'E– i Designer: is of 310 CMR 15.00 (Title .5) `arW the approved design plans/as-built plans relating to 60. Approved Design Flow 3 S Z- (gpd) Inspector: ----The issuance-of_this_permit shall not 6"ojtrued as a_guaranteeee_that the system will function as designed. COMMONWEALTH Of MASSACHUSETTS Board of Health, , MA. DIS T y G/ FEE 01 efo Permission is hereby granted to; Construct( Y) `Repair( ) Upgrade (,,�Abandon( ) an individual sewage disposal system at / 7 5 -VI 2- /l// i � - � as described in the application for Disposal System Construction Permit No. , dated 1 -Provided: Construction shall be completed within three years of the date of this permit. All local conditions mus e met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date CJt..�Soard of Health No. 6T �Zj 4 Board of Health, YARMOUTH HEALTH DW-, 114e ROUTE 28 ,"11�A.APPLICATION FOP, DISP(ftTA9YM ")�WUCTION FEE 'Ga 11- &kqj� A PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location -o Owner's Name © (� Map/Parcel# �� //ac) Address Lot# sT S'� �� Telephone# Installer's Name �� e t �� Designer's Name t Address % S Address -7 Telephone# "� Telephone# %JV7 — flj Type of Building �����cSLe�-� �-� Lot Size Dwelling - No. of Bedrooms 3. Other - Type of Building No. of persons sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 3w�� gpd Calculated design flow �`'�� Design flow provided S34 gpd Plan: Date �/ l `��� Number of sheets 1 Revision Date Title �`® \ L. Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator 1Atj K `r-- Date of Evaluation -A - 6 -00 DESCRIPTION OF REPAIRS OR ALTERATIONS 1 — Ow- 5 The undersigned agrees to install the above describe„0 Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur th em on until a Certificate of Compliance has been issued by the Board of Health. Signed Date a Inspections No. � FEE dy COMMONWEALTH OF MASSACHUSETTS Board of Health, IA e -i Ao C , MA. CERTIFICATE OF COMPLIANCE Description of Work: X,Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned ( ) by: at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. "Z%16 , dated 45; pproved Design Flow 49pd) Installer Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. (� /� / [.�� FEE . COMMONWEALTH Of MASSACHUSETTS Board of Health, `! V4aAki 3` MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(() Repair( ) Upgrade( Abandon ( ) an individual sewage disposal system at C1 Q46, as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed within thr years of the date of this permit. All local conditions m t be met. Form 1255 Rev. 5/96 A.M. S `-� Sdfkin,Co. Boston, MA Date `Board of Health y"”`