HomeMy WebLinkAboutApp-Permit-Construction41 1 YARNAOU I-, HEALTH DEPT.
No.—GU-33a 1146ROUTE 23 FEE F.-
SO. YARMOUTH, MA ®2664'
COMMONWEALTH Of MASSAC14USETTS
Board of Health, , MM.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location 5'-( -SI /Y/Zt Ctdff2j,� S� �jrf/P
Owner's Name do? 0V S F
Map/Parcel# 4-141
Address Aj i/PCVV Y 2�,e Sc ,JO
Lot# A/0
Telephone# f Q r. g 7 L
Installer's Name 4 1F l A-1CQ
Designer's Name
Address 3S' pw* 5 r ftp
Address
Telephone# % 7 S - A i0 p
Telephone#
Type of Building b a 'ol g k 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 Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I Alt C h.4ti4- F '7i3A-/1C -7o' .4/7 -
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 to place the syste m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Y--d.0-7r
Inspections
(� ^� (� N�
No. FEE
O �3) �: COMMONWLALT1®F MASSACHUSETTS
ETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (k, Upgraded ( ), Abandoned ( )
by: ' g/? C14tiCa 350 /Y/f9/v ST LV - r ,V
at .s V- S G ,12 F iP Cy R Y/'i S G K4 /e
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. )-- , dated gyp_ "t Approved Design Flow (gpd)
Installer 37-3-
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guar, tee that the/system will function as designed.
No. `? 611- 3 �S FEE
Board of Health, r�c.�/` ' MA.
DISPOSAL SYST & CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair(j() Upgrade( ) Abandon( ) an individual sewage disposal system
at S y - 56 I)Y Flf Cy R Y --7) P S a ��4 as described in the application for
Disposal System Construction Permit No. 3 dated `/ .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health