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HomeMy WebLinkAboutApp-Permit-Compliance�c No. YARMOUTH HEALTH DEPT. © 7 1146 ROUTV� FEEy(/ 5V/t/` AoWa� Board of Health, /l ✓ MA. B APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMITF rb)1y� Application for a Permit to Construct( ) Repair( ) Upgrade(x) Abandon() - ❑ Complete System J Individual Components Location 1.2(IR" Owner's Name Map/Parcel# Address Lot# Telephone# Installer's Name Designer's Name , ITIA Address Address tTele7phone# p Telephone# W Q Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms 3 Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) 3� gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not�t -place the system in operation until a Certificate of Compliance has been issued by the Board of Health. tigned 1�j Date Yjwlal iInspections No.� { FEE C®MM®NWEA119 -dMASSACHUSETTS.v Board of Health,'" 1.- MA. CERTIFICAA OF COMPLIANCE Description of Work: ❑ •Individual Component(s) ❑ Complete System The undersigned hereby certify,that the Sewage Disposal System; Constructed( ), Repaired ( ),Upgraded , Abandoned( ) by: at has been installed in accorda t ndeyvith.�£h��"i•�vis�i`pns.of�310.,:CMR 15.OQ (Title 5) and the plans/as--built plans.r¢'laiix:€g tas. - - application No. 6-,)/ - �� , dated 7 .) AVprl V"e1dD6sign Flow (gpd) Installer Ute--l✓� l— Designer:' r ,kiasp Victor: Date: •its � '�'` ! The issuance of th �erm�i't `shall Lot be construed , as �,>ngs?t antee that the system will function as designed. jc+'d 1 No. 7 c v ; + �'>(D�It� / / " .�%�(�� FEE Ile} �,COMMONWEAI.114 OF -MASSACHUSETTS/ Board of Health, �� �''L _ MA. DISPOSAL SYSTEM CONSTRUCT1®N DEBAT Permission is hereby granted to; Construct( ) Repair( ) Upgrade (Abandon( ) an individual sewage disposal system at Z -:2 Z �ZZ , /as described in the application for Disposal System Construction Permit No. /�/ _ 5, dated 2 7 -L -,-)l Provided: Construction shall be completedwithinth of the date of this permit. All local conditions ust be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / % 7-/ Board of Health / �/