HomeMy WebLinkAboutApp-Permit-Compliance\, 1146 ROUTE 26
No. 9 SO. YARMOUTH, MA 02664
COMMONWEALTH Of MASSACHUSETTS
Board of Health,
FEE 6 C.1
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location,--,?
1-
Owner's NameA & �dC
Map/Parcel#
A02-33—<�—
Address -2
Lot#
Telephone#
Installer's Name
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Designer's Name v
Address S60
Address
Telephone#
s - �'�
Telephone#
Type of Buildingli%�llT/�✓�� _ _ 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) .'350 gpd Calculated design flow _�� Design flow provided ,---W -7,� gpd
Plan: Date Number of sheets Revision Date
Title
F
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersign grees to install the above escribed Individual Sewage Disposal System ' accordance with the provisions of TITLE 5 and
further afire t to c operation until a Certificate of
Co ph ce as issued by the Board of Health.
Signe Date oC
Inspections
I
No. % C®MMONWEALT ®F MAS 14USETTS FEE
Board of Health, MA.��
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
Th
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. - 3 dated 2 "7>proved Design Flow (gpd)
Installer Q /?64
Designer: Inspector: Date: 1-�-
The issuance of this permit shall not be construed as a guarantee that A system will function as designed.