HomeMy WebLinkAboutApp-Permit-ComplianceNo. Dib .� O / / �/ �G FEE
MMMMWIFAITH OF MASSACHUSETTS
Board of Health, ,
YARMOUTH HEALTH DEFP
1DIA.T.
1146 ROUTE 28
APPLICATION FOR DISPOSWI'�VWWM�MRUCTION PERMIT
Application for a Permit to Construct( ) Repair(A<'Upgrade() Abandon() - ❑ Complete System k5dividual Components
Location :3 SAA -,11,41P FIr AA, (,v ^ �/F%(
Owner's Name e' L L m v/P'DoC lr
Map/Parcel# �—
Address !6 �ic>£LL / Job 10
Lot#
Telephone#
Installer's Name
Designer's Name
Address 3 ,5-,g/N �_ cfW�
Address
Telephone# 11'-11 $ _9 9x -11 -F106
Telephone#
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
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
DESCRIPTION OF REPAIRS OR ALTERATIONS 07 4/N
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to not to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No.
l FEE
COMMONWEALT Off' MASSACHUSETTS-).
Board of Health, %/� MA.L
CERTIFICATE OF COMPLIANC
Description of Work: &Lndividual'Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (t_!