HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE ��
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,3ar /T OMMONWEALTH Of MSSAC14USETTS V
Board of Health, YARMOUTH HEALTW@EPT.
AP ATI®N fOR DISP®SA. &i�T .TI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
-1 9
Owner's Name
Map/Parcel#
411-?iU (>i 3
Address
Lot#
&P s32—
Telephone#
Installer's Nam
Designer's Name
Address
!
�.� ress ! 7 /�, t
Telephone#
D ��'
Telephone# .�
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Lot Size
sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided 537 gpd
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS -'C
Revision Date
Date of Evaluation
The undersi a Zto't the ab a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthera es n syst in operation until a Certificate of mp7-6 ce has been issued by the Board of Health.
Signed t'— Date - /�
Inspections /.J % 6 03 S�
G
No. 504 FEE
�®MX4®1XY X F11TU1 ®r MAQQA UIITQETTQ
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired'( ), Upgraded4<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. 6V - S6 4' , dated /li' 'e5 Z0 . Approvedhesign Flow 3-�> :7(gpd)
Installer
Board of Health,
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) & Complete System
Designer: _.42jaR-AV Inspector:
Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed_
No. )2. F, f� 7<. // / /G FEE
COMMONWEALTH Of MASSAC14USETTS el
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT _
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( KAbandon( ) an individual sewage disposal system
at / Z %JAL�+7cf// �= as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within -ti rsof the date of this permit. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Boston, MA Date//Board of Health
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