HomeMy WebLinkAboutApp-Permit-ComplianceYAHMUU I H HEALTH DEPT.
No.
5 1146 ROUTE 28
SO. YARMOUTH, MA 02664
COMMONWEA HOF MASSAC14US ETTS
Board of Health, MA.
FEE
b ff 3 J��
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
® 5� �,�
Address
Lot#
Telephone#
Installer's Name
Designer's Nam
Address
,
Address
lli r
Telephone#
Telephone#
Type of Building (6 M6 Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min.
Plan: Date 1 P
Title
Description of Soil (s)
Number of sheets
Soil Evaluator Form No. Name of Soil Evaluator
�J &K. ( 411 YU4 ,, Date of Evaluation t.�ff` I `(x,)
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal Sy, tem in accordance with the provisions of TITLE 5 and
further a oft .p a the in operation until a Certificate o ompli has been issued by the Board of Health.
signed Date
Inspections
No. 50 FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA. G 3366
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) C Complete System
The undersigned hereby cer ' that the Sewage Dis osal System; Constructed ( ),.Repaired ( ), Upgraded ( Abandoned ( )
by: VW
at
hhs been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
t—
application No. v dated 9 — -��Approved Design Flow (gpd)
Installer
Designer: Inspector: P,6 Date:
The issuance of this permit shall not be construed as a e that the system will function as designed.
..-. ..,
No.J�� FEE
COMMON 14
��ASSACHFSPW�,(-)
Board of Health, W nk- MA.
DISPOSAL "SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (� Abandon( ) an individual se*vage disposal system
at 4144 tL,V as described in the application for
Disposal System Construction Permit No. dated - —
Provided: Construction shall be completed within .4 of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / ! 5 Z),�oard of Health /' l�