HomeMy WebLinkAboutApp-Permit-ComplianceNo. O7' -� 74
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ETTS
YARMOUTH HEALTH DECOMMONWEALTH Of T.
Board of Health, 11465 ROUTE -2$ , mi.
APPLICATION FOP, DISP® MM ' M tUCTION
Application for a Permit to Construct( ) Repair �4pgrade( ) Abandon( ) - ❑ Complete System
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION
FEE 5G3'
3' V�
G3C�(�UE '0MMD
n�,g-w�� s 2007
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd:
Revision Date
Date of Evaluation
ALTERATIONS &ZV f�� �'�.(' ✓J n Q
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 system 'opera"on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date d I
Inspections
No. V �tY9 �r-�\ FEE
Y
COMMONWEALT14 OF MASSACHUSETTS
Board of Health,, ��%?7/% C� �L , MA. /
CERTIFICATE Of COMPLIANCE
Description of Work: Cndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Q//Upgraded ( ), Abandoned ( )
has been installed in accorda ce with the provisions of�0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 0 - dated 2 ' �Z -0 Approved Design Flow (gpd)
Installer �j C. ` /)Y,
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gu
�th.t the system will function as designed.
No. Q CFEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, V" 61 LU T/ 1-1 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
IT GU
Permission is hereby granted to; Construct( ) Repair ( /,)'Upgrade ( ) Abandon( ) an individual sewage disposal system
/;.
//��ii -7 as described in the application for
Disposal System Construction Permit No.y 7 . , dated 2 -�� -L4!.
Provided: Construction shall be completed within dw�= of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date2— /�--0 % Board bf Health
Owner's Name Z O
r
`&)
Address "/3S�l ow / Lt.7 %f
Telephone#-
�, e /? T
Designer's Name
Novb r g l J l
Address
Telephone#
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd:
Revision Date
Date of Evaluation
ALTERATIONS &ZV f�� �'�.(' ✓J n Q
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 system 'opera"on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date d I
Inspections
No. V �tY9 �r-�\ FEE
Y
COMMONWEALT14 OF MASSACHUSETTS
Board of Health,, ��%?7/% C� �L , MA. /
CERTIFICATE Of COMPLIANCE
Description of Work: Cndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Q//Upgraded ( ), Abandoned ( )
has been installed in accorda ce with the provisions of�0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 0 - dated 2 ' �Z -0 Approved Design Flow (gpd)
Installer �j C. ` /)Y,
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gu
�th.t the system will function as designed.
No. Q CFEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, V" 61 LU T/ 1-1 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
IT GU
Permission is hereby granted to; Construct( ) Repair ( /,)'Upgrade ( ) Abandon( ) an individual sewage disposal system
/;.
//��ii -7 as described in the application for
Disposal System Construction Permit No.y 7 . , dated 2 -�� -L4!.
Provided: Construction shall be completed within dw�= of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date2— /�--0 % Board bf Health