HomeMy WebLinkAboutApp-Permit-ComplianceFEE la,
CO[MONWEALT14 OF MASSAC14USETTS
�/� ✓YI(�1/�� Board of Health, YARMOUTH HEALTH
1148;. ROU
/,� PLICATION FOP DISP0 � , 9C UCTION PERMIT
Applica" tidn for a Pe mit to Construct() Repair() Upgrade() Abandon() - ❑ Complete System ❑ Individual Components
Location Os- A2J
Owner's Name
P Buri Coag-rz
Map/Parcel# / ,5MA-p PAa-C� i
Address
Lot# ZoT / /
Telephone#
Installer's Name 0;m e5 LLQ.-
Designer's Name
YAJ&, C-961 Af &M)
Address T, 13o4 ''%0?- M,44-9-0 tJ C MI US I A4Address
'&K.
°713 S, baidis MA
Telephone# 5-0 ,'0 v
1 Telephone#
9'Z�f" c 3 q r, 3 q� y
Type of Building KLA 1
Dwelling - No. of Bedrooms _
Other - Type of Building _
1 ki.,
No. of persons
Lot Size / sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. equi ed) gpd Calculated design flow Design flow provided 3 ' gpd
Plan: Date to
® Number of sheets Revision Date
Title
Description of Soil(s) SCS IZ6 DAf
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install th above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree to not to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed / Date
� r
. _ i1 . � .-•L - -- , , ./' t'--,� - - ,. _ � n i /ray
No.
FEE /4. 1
Board of Health, VA-e-r1,QDUnj MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed /"Repaired ( ), Upgraded ( ), Abandoned ( )
by: 14o wye + S D 1J (d. by s -r- . .
at / D S' W I Pref Al b )20 A -D
has been installed ip ac(
application No.
y+
�
Installer 7 ! J4-vv1 Gz
with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated 4 '?-'7 . - S Approved Design Flow .3, (gpd)
3
Designer: SLJ8�rrSF2 (a&1JF&-;P-lAh Inspector: X G; y l.�! ''rC Date: / L/
The issuance of this permit shall not be construed as a gua Anntee th t the system will function as designed.
No. U% / i f� G G f- Y� c4.Q A FEE G
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, Vkl art 4 n rA i , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at % E S W I A -d MP XOA-J� as described in the application for
Disposal System Construction Permit No. tjl- dated 6, Z
� (�l�Gt7 S'
Provided: Construction shall be completed within tars of the date of this pe'mit. l local conditiops must be met.
/ Form 1255 Rev. 5/96 A.M. Sulkin Co. Bost/on, MA, Date 6 Board of Health