HomeMy WebLinkAboutApp-Permit-ComplianceNo. V /
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COMMONWEALTH OF MASSAC14USETTS
HEALTH DEPT
: Board of Health, YARMOUTH MA
APPLICATION FOR DISP®SM' W4TMIWCTION PERMIT
Application for a Permit to Construct(/Repair( ) grade() bandon() - OQComplete System ❑ Individual Components
Location
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Owner's Name4S/ Q#- CLAWC /lI/e-/1dLS
Map/Parcel#
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Address e�%/0 bDRE le -404-0
Lot#
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Telephone# ""�('-,-73-7- o- /
Installer's Name 0#7r
Designer's Name S7"fPNfW
Address P ,gam
o UZW A"(7
Address ( ()
Telephone# jbo
—34' q —SVR
Telephone# a1 —
Type of Building J//V67t& F -X?,
Dwelling - No. of Bedrooms 7
Other - Type of Building 4LA
No. of persons
Lot Size/o2/ 4 0 0 sq. ft.
Garbage grinder ( )
QZ Showers.( , Cafeteria ( )
Other Fixtures N/H'
Design Flow (min. required) ._5.�0 gpd Calculated design flow 230 Design flow provided gpd
Plan: Date /' /���Ol► Number of sheets / Revision Date A1119
Title ; SA—?/'/d
Description of Soil(s) /iJE'0/0M .S/1W Q C_(_f1�J (V/
Soil Evaluator Form No. Name of Soil Evaluator .92P -4 Z1 144M Date of Evaluation
DESCRIPTION OF REWRS OR+ `ALTERATIONS /L/ Id �r%C/S /)6 6TSSIdl;� AIM �fl�S%T�LJC_
1,16-60�W
ne
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to
/ ace th tem in operation until a Certificate of Compli nce has been issued by the Board of Health.
Signed/!/ Date
Inspections
F
No. �-� FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, h� / l tit 0,,—, H MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) O. Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired),Upgraded ( ),Abandoned ( )
G H I Ti'Z iN ��. /A ,V i) C � � l ll �^ l '�..I
by: � r
at ? e1 C6~ 1218 1 iV 1.)cilG 1c' r
has been installed in accolydWce with the provisions o1310 CMR 15.00 (Title 5)and the p roved design plans/as-built plans relating to
application No. �-7 _ �—O , dated Q- —6 —6'S Approved Design Flow/ o(gpd)
Installer C f / I iT ,� , (_ f1 i�, j C /-j t)l N r dXPI A,10
Designer: Inspector: ! .// Date: /. —1113
The issuance of this permit shall nofbe as a guarantee th t the system will function as designed.
V
No.S FEE
COMMONWEALTH OF MASSACHUSETTS zXy) 3
Board of Health, `/r.,��4_ /yt O�-�-E- , MA.
lV
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade'(4-} Abandon( ) an individual sewage disposal system
': } 1 (� as described in the application for
Disposal System Construction Permit No. �� ddated
Provided: Construction shall be completed within -t _1 o�the date of this -per it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / X1 Board of Health t