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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6 .,VA1/�ZBd x hh YARMOUTH HEALTH DEPTT. FEE Q OVL oa ��r of ea 1146 ROU I E 28 APPLICATION FOP, DISPOW-AR" k%9MfKUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(eAbandon() - ❑ Complete System Individual Components Location Owner's Name klle- Map/Parcel# �� 3 Address Lot# Telephone# Installer's Name Designer's Name QQ'lg Iq 6ee �J� AV Address (,�� r , Address Telephone#- Telephone# Z - r Type of Building X es/,-? ell � Lot Size ./5 sq. ft. Dwelling - No. of Bedrooms 13 Garbage grinder Other - Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. Plan: Date Title Description of Soil(s) Soil Evaluator Form No. gpd Calculated design flow 3T34-�9 Design flow provided) J� gpd Number of sheets / Revision Date DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t of o pl th stem in o eration until a Certificate ofL.CCo pliara has been issued by the Board of Health. Signed Date ! �� Inspections 12 —4y' --Oz /it r r�" ref-,iZ,5PA► ) V o'1 All /4,40,1 d u --Cl U. h&V No. 6J- —06 Description of Work: The undersigned het by: e% %/ at 7.3- z Board of Health, MA. CERTIFICATE Of COMPLIANCE FEET -76� "dividual Component(s) 0 Complete System by certify that thh Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded k -<Abandoned ( ) />�f-- has been installed inllaccordannee with the rovisions of 310 CMR 15.00 (Title 5) and die approved design plans/as-built plans relating to application No. 1 o , dated :��—� Approved Design Flow (gpd) Installer Designer: �%/Q � � � Inspector: Date: The issuance of this,permit shall not be construed as, a guarantee that the system will function as designed. No. ©� " •aOlo Oi /� C L � FEE 50, C®MMONWEALT14Of MASSAC14US ETTS Board of Health, /e/ ���7i1' , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to;; Construct( ) Repair( ) Upgrade(✓) Abandon( ) an individual sewage disposal system at 2.3 0/��/ 4 ,i as described in the application for Disposal System Construction Permit No. �.� � , dated G)/ro Dz.- Provided: Construction shall be completed within191?f the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 1 Z --Board of Health Q r LL 7'n ,, C 011'-;:-7— �.fl ii ./s YYl/A " "07