HomeMy WebLinkAboutApp-Permit-Compliance" No. � _ 1146 ROUTE 26
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSACHUSETTS
Board of Health, y4,gf,7Z--, , MA.
FEE ���
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade ("�bandon( ) - ❑ Complete System ❑ Individual Components
Location
of OVzV' �;7, % Owner's Name P10_%Z4_Z.
Map/Parcel#
Address 3 % �. f 1L 2d z.✓✓Z�
Lot# 3 6
Telephone#
Installer's Name
Designer's Name
Address�J
s
Telephone;—
-7� �' elephone# Z Z
/ 2 035
Type of Building � r �4""�c V- Lot Size (/� sq. ft.
Dwelling - No. of Bedrooms 'Z^ C l Garbage grinder (''O
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. re uired) —7 gpd Calculated design flow Design flow providedZ L gpd
Plan: Date `r 7 / Number of sheets I Revision Date. V 60� %
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil EvaluatorDate of Evaluation
The undersigned to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to 0 o pdage the em ' ati til a Certificate o omp
,,Signed he as be issued by the Board of Health.
Date
Inspections
No. _gt T 1f 6 1!!1�� ���\\yyAA''�ff� �T��%E rp Trp FEE
ETTS
Board of Health, NIA. G
CERTIFICZ, OF COMPLIANCE` -
Description of Work: ❑ Individual Component(s) Complete System
The under�ga d hereby certify thaj*e Sewage Disposal item; Construc/ted`( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
I'J< T_I
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the
application No. L�';, , dated .� 5' ��% Approved Design Flow 3:3,
Installerc`Z S .
Designen. Inspector:
The issuance of this permit shall not be construed as a guarantee that the system will fun
design plans/as-built plans relating to
)d)
Date: Cj �r
designed.