HomeMy WebLinkAboutApp-Permit-Compliance— �5
COMMONWEA&e T4 � jgl�kjTS
Board of Health, 1146 ROUTE 28 MA.
YARMOUTH, MA 02664
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMI1
FEE
Application for a Permit to Construct( ) Repair(v6pgrade() Abandon() - ❑ Complete System individual Components
Location ��la G� p/c,
Owner's Namezr-0,) , Izzz
Map/Parcel# /0. ' 7
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address 16 /
Address
Telephone# =
Telephone#
Type of Building 21)�-ten �11�.4 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)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided gpd
Revision Date
Date of Evaluation
7 kX Cay 1'? -1 R Ikyt
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr�t =plMetemin operation until a Certificate of Co pli ce has been issued by the Board of Health.
Signed s Date
Inspections
No. f
FEE' lti
Board of Health, /Y MA. <
CERTIFICATE Of COMPLIANCE � ' \' L7
Description of Work: I�'Individual Component(s) LlComplete System /
The undersigned hereby/certify that she Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned
by: £ave vJ
at V C
has been installed in accord with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. % '1 O , wed �(( �? Approved Design Flow (gpd)
Installer
cuP
Designer: Inspector: Date: Ifl I.1. �--P 7
The issuance of this permit shall not be construed as a guarantee that the system will function as des�ed.
No. J7 /� l % /r7 � �i� i rr \ FEE $2% d0
COMMONWEALTH Of MASSAC14USETTS A0 �T%°
Board of Health, GliL MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(�Upgrade(
at / 6;tCGt`.- I-KArd / Z
) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. o 743 dated ^d
Provided: Construction shall be completed within dtree-qho
the date of this perm't. All local con itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health