HomeMy WebLinkAboutApp-Permit-ComplianceNo. � �Z/ FEE
COMMONWEALTH OF MAS CHUSLTTS �
YARMOUTH HEALTH DEPT.
Board of HealtJMA.
APPLICATION FOP, DISP AfTRWtWRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair /,upgrade Abandon() - ❑ Complete System ❑ Individual Components
Location 1'( Znd,�A.� M$rY dtgA.
Owner's Name
—ftKrwe
Map/Parcel# MAS'; .— K g
Address
'5�q
Lot# �.
Telephone#
Installer's Name A 8 CANco
Designer's Name
T/q( C7
Address 350 Main Street
Address
Telephone# W.' ' MA U2673
Telephone#
Type of Building f�{ S Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No, of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) v73o gpd Calculated design flow
Plan: Date Jam` - 3v_ O -e> Number of sheets C
Title
Description of Soil(s)
Soil Evaluator Form No.
rA
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided gpd
Revision Date Al
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
farther agrees to not (lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed t J Date —aa
M
Inspections
No. COMMONV'y LALT14 Of MASSAC14 SETTS FEE
Board ofHealth,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.Y,-U,--Pgraded ( ), Abandoned ( )
by: C'.�4/� C U
at /� .L i!Q i.rl�tJ // �4H+dt..e 'I i •�..t/�
has been installed in accordanoQg with the provisions of 310 CMR 15.00 (Title 5) and the aaiproved design plans/as-built plans relating to
application No. , " .� dated Approved Design Flow :3!f (gPd)
Installer f_ �fitC 7 r7
Designer: TPS/ `%� Inspector: Date: / ^✓�=/
The issuance of this permit shall not be construed as a guarantee that the system will function as designed..
No. �3 /L��Li' FEE J O
COMMONWEALTH Of MASSACHUSETTS loG �ix.�1746
Board of Health,2.i, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;; Construct( ) Repair (,er" Upgrade ( ) PAbandon ( ) an individual sewage disposal system
at ,14i —Zf?,nO� :A o/ i�.�! ✓I t�. Y'��.�. as described in the application for
Disposal System Construction Permit No. . , dated -23
Provided: Construction shall be completed within th-re the date of this pernit� All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date n 2 C/Board of Health \