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HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEATH DEPT. No 3- 7S' 1146 ROUTE 28 FEE �50-dV W. YARMOU I M,IMA 02664 Boll Z //cAPe'7-COMMONWEALTH Of MASSAC14USETTS Vj 6t ©0.4 Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - complete System ❑ Individual Components Locational 'CCiL�✓ Yv q�_ ��� Owner's Name .0- T e (Z- Map/Parcel# '3 XD Address S Lot# eo Telephone# Installer's Name M, a Designer's Name s /ansa i Address -a"D v Address 22 4�V �Telephone# Telephone# Type of Building V► AL Dwelling - No. of Bedrooms 13 Other - Type of Building Other Fixtures No. of persons Design Flow (min. required)—'73 3 gpd Calculated design flow Plan: Date / Number of sheets Title iia ✓'iii✓ Description ofSoil(s) Lo►qwn-;a-S/¢4 6otq 12 Soil Evaluator Form No. Lot Size sq. ft. Garbage grinder ( ) Showers( ), Cafeteria ( ) Design flow provided Revision Date Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS V� gpd The undersigned agree to install above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 7 2'7f� Inspections 30 No. 7.5FEE SZ- 60 'l.OMMONWEALT14 OF MASSAC14USETTS . Board of Health, MA. p� CERTIFICA&OF COMPLIANCE Description of Work: ❑ Individual Component(s) +Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded 1-}, Abandoned ( ) by: 5 at - G v' O.Q— has been installed in accordance with the provisio11s of 0 CMR 15.00 (Title 5) and the P�`roved design plans/as-built plans relating to application No. ? Z'%� , dated'? "- �/ Approved Design Flow , Z (gpd) Installer //Iii C^17Gr Designer: Inspector: Z�G Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. O ' Z lw%v, `i ,6- G. FEE COMMONWTALT14 OF MASSACHUSETTS Board of Health, VA 0 PLb•-4-" I , MA. DISPOSAL SYST CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair ( ) Upgrade (7`) Abandon ( ) an individual sewage disposal system at Disposal System Construction Permit No. dated 7-S- W . as described in the application for Provided: Construction shall be completed within three years of the date of this permit. All local conditions in t be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date7 �� �6 Board of Health(✓ •T..P ., i / _ � /C 17.---.._ � C _ . —, ..� �,�.. si. � epi