HomeMy WebLinkAboutApp-Permit-Compliance/ YARMOUTH HEALTH DEPT.
No. 00 -S:3 1146 ROUTE,28 FEE
' SO. YARMOUTH, MA 026/66// I -D //f COMMONWEALTH OF MANSACHUSETTS
RA ✓j�rno��cJ rd
Board of Health, , MA.
APPLICATION FOR,.DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()epair( ) U rade(�l7bandon() - Complete System LJ Individual Components
1MAt i' 62e_
o..
Location - (�t.tyr�
Owner's Name (g(,j HroW G 0 0�ro
Ma /Parcel#
p �� � 5 /
Address (r
a�3 V
Lot# ZCo 2
Telephone# 3 _ (0
Installer's Namezr u CC l 0 �5-
Designer's Name ® w �e& hSiC lsiJri
Address( (< TCa�u ��
Address X s C v�
Telephone# - SS02
Telephone# .1 5'
Type of Building T C. c tt` "ex, Lot Size
Dwelling - No. of Bedrooms 1
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required) L-ALAO gpd Calculated design flow _�49
Plan: Date OCT l0 '` 06 Number of sheets
Title
Description of Soil(s) A3 F« p(An
Soil Evaluator Form No.
Name of Soil Evaluator
Z Re /,-� sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
P,
Design flow provided � gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS 15 -co G al, 17'-026 ►. _b -so x e"",
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to not to plaa the sys m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �u� �c Date 0'C77o2 !f- DO
Inspections 1
No.
;41
COMMO � LT14 OF MASSACHUSETTSFEE
f � r��'�
Board o Health, /1✓!. ✓af on--/ , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 'Complete System c
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (/)'; Abandoned O
by:
at� F`7�/fit 7'2J2 E �C-%r
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5).and the proved design plans%as-built plans relating to
application No. C, at d ��' Ob Approved Design Flow4 S gpd)
Installer ' �.y2 f, :7 . d
Designer: Zh /-- e-1-/ Inspector: �wf/ Dater
`
The issuance of this permit shadnot be construed as a guarantee that the system will funcrtign as designed.
No. e; — '�T3 FEE JC/ . 41 i
COMMONWEALTH OF MASSAC14USETTS 7f�
Board of Health, r —u- All/1i/i7� �,MA.
DISPOSAL SYSTEM CONSTRUCTION
PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(�bandon( ) an individual sewage disposal system
at -2 :h AM ��A/ � -" as describecb,in the application for
Disposal System Construction Permit No. r 3 dated.
Provided: Construction shall be completed within t'oshe date of this permit. All local conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date'4_1_16 Board of Health