HomeMy WebLinkAboutApp-Permit-Compliance,— YARMOUTH HEALTH DEPT. FEE
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ACIIUSETTS
0 k Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair V�Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location T# cio%o
M, /3
Owner's Name
Map/Parcel# Sq
(U(a) KAP q& ' PAkCGL-
Address
Lot#
15
L LI'5
Telephone# 9
62 _ Q 79
Installer's Name
��ITG
Designer's Name®, !V 6WJdN. _
Address�o �
e
Address q3 71-ING-6— J��W
Telephone#
I Telephone# -
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow
/(�miipn. required)
Jp gpd Calculated
/design flow Design flow provided 3J/- i�gpd
Plan: Date f 7� ,�+�- LI/ 6 o? Number of sheets / Revision Date ! a -a .3 -919 -
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS / �• �Cr�� 1/ or" � . I/W�7L-L
11� LZ" ARY-40 Z� 6!� f
The undersigned agrees to in,
ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree no4om ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ,7 ��/'!?q
Impections
No. FEE
C®MMONWEALT14 OF .MASSAC14USETTS
Board of Health, ✓%'!%/7` , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired V, Upgraded ( ), Abandoned ( )
by: , RAIV 6`oT1225 65),(j f•
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. C?'i ` 9-5 , dated ^ " 1. �. Approved Design Flow—C-
(gPd)
Installer t3p/.AN AyorTK 60A67-1,,
• , n
Designer: e5760 - %6:�I 1 Inspectort 6nng�DN' , Date: q"(a f
V
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
P
No. 's 3 ��D %� , FEE o _ •--
Board of Health, ( /, 9W , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair M Upgrade( ) Abandon( ) an individual sewage disposal system
at 27 COC tib as described in the application for
Disposal System Construction Permit No. dated �-
Provided: Construction shall be completed within three years of the date of this ppeermit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date '`/ Board of Health��-;�