HomeMy WebLinkAboutApp-Permit-ComplianceNo. --.),77 FEE �✓
COMMONWEALTH Of MASSAC14 SETTS
YARMOUTH HEALTH DEPT.
Board of Health,11 46 ROQTE 9 , MA.
APPLICATION FOR DISPO��WftTMMIJCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
G 1 ,n in,Owner's
Name ,Lc- r b
Map/Parcel#
�S
Address r C. ,
Lot#
Telephone# S� r
Installer's Name
i
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building /,I h 1 ) S 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
DESCRIPTION OF REPAIRS OR ALTERATIONS V( t 1 43 1 f'
Design flow provided gpd
Revision Date
Date of Evaluation
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 in operation until a Certificate of Com fiance has been issued by the Board of Health.
Signed 6 6 ��� - Date O
Inspections
N�Z7eo
Description of Work:
The undersigned her
by:
at
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COMMONWEALTH Of MASSAC14USETTS
Bbardof Health,
CEPITIFICAT'E'Of COMPLIA
rGQ 1Individual Component(s) ❑ Complete System P �� j pernc�
certify that the Sewage Disposal System; Constructed
%
Re , Upgrade ( ),Abandoned(
(
71-17
<j u= yx� -
has been installed in a
application N16 -4 ---
Installer Z N • !/
with the provisions of 310 CMR M00 (Title 5) and the approved design plans/as-built plans relating to
date & - Approved Design Flow - (gpd)
Designer: Inspector: 1 Date: / 17ZO Y
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Nd/ % A' /% FEE 4
COMMONWEALTH OF MASSACHUSETTS
Board of Health, I J191,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repa� Upgrade ( ) Abandon( ) an individual sewage disposal system
at al-,2z�/�-�' as -,described in the application for
Disposal System Construction Permit No� -�-% , dated `
Provided: Construction shall be completed within three years of the date of this -per it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Daie7-I -64t'
Board of Health f