HomeMy WebLinkAboutApp-Permit-ComplianceNo.JrL FEE JJ
YARMOUTH HEALTH DEPT.
Board of Health n .6 on, TE no , MA. ,
APPLICATION FOR DISPMAT.AUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location�C'
Owner's Name ..
Map/Parcel#
l6 —
Address
Lot#
Telephone#
Installer's NameU�/'��
e
de
Designer's Nam
Address
r sC
Address
Telephone#%�—'
6 —� (j
Telephone# .. �.
Type of Building 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
Name of Soil Evaluator
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS/� /G'� �'�� I ��`L°��� � VS /7/
The undersign gre s to install the AZve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a not o Kja i tion un 'Certificate of ComBAance has been issued by the Board of Health.
Signed Date
Inspections
No. C®1`�ll��®N �'�Y jC.1�tLTl-Jt OF �SSA'l.� �!J ETTS Qk f `�( �� 9 FEE��
C�Z/ "Y 7071
Board of Health, / MA /
CERTIFICATE OF COMPLIANCE 0
Description of Work: 'individual Component(s) ElComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( , Upgraded ( ), Abandoned ( )
by: �!2 Tibf( /4zs L/ y y uc7 G
at
has been installed in
application No. 01
Installer 11'% _)/)y
with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
did q — . Approved Design Flow (gpd)
0
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
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No. 9FEE
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COMMONWEALTH OF MASS CIIUSETTS
Board of Health, l/Ut MA.
DISPOSAL SAYS M CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair (/Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. A , dated 4--6)
Provided: Construction shall be completed within thxee.aar ol'thT date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date9-- 7 6 Board of Health
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