HomeMy WebLinkAboutApp-Permit-ComplianceNo t/'1I FEE
COMMONWEALTH OF MASSACHUSETTS
/L Board of Health, YARMOUTH HEALTH DT.
APPLICATION FOP DISP® : ` 1HTCTION PERMIT
Application for a PermitConstruct ( Repair(4-Upgrade O Abandon( ❑ Complete System ❑ Individual Components
Locatio
Map/Parcel#
Owner's Name
2— Address `j Q
Lot#
Telephone#
Installer's Name
Designer's Name
Address 3 a
t. Address ---
Telephone#
Telephone#
Type of Building 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) gpd Calculated design flow Design flow provided_ gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils) w�A—PSI 7a -f
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 a s to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �+ Date Jif.'
Inspections -Soil �7t "'"/���� 1�-- #Zvo y D
No. �_ir/'�'- C®MM®1V` V'V' �LT�tlt Of MASSACHUSETTS
FEE-f�l�c�-'�c.c
Board of Health, , MA. l b Il
C EPITIFIC ®F COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (n�j', Upgraded ( ), Abandoned ( )
by: a
at
has been installed in accordance with the provisions of 310 CMR 5.00 (Title 5) and e ap roved design plans/as-built plans relating to
application No. " .Z- dated � " -64 . Approved Design Flow 99 (gpd)
Installer
Designer: lia g G' -4e- Inspector: 401,J Date: /
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. � Com. 4kc h FEE IeTd • C/�+'
Board of Health, , MA.
DISPOSA S YST 'ONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(v) Upgrade( ) Abandon( ) an individual sewage disposal system
atS� % / i -�.y, �.%� �� �1j ��/�r as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within thhrr 10 19 of the date of this permit.
All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date b (/`7 Board of Health ' . �4/�V ;
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