HomeMy WebLinkAboutApp-Permit-ComplianceNo. L� FEE
Xt�/�7/OrDMMONWEALTH Of MASSAC14USETTS
Board of Health, YARMOUTH HEALTH Dom.,
APPLICATION FOR DISP0 A&UCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location f / G
mak, C3 "
Owner's Name%
Map/Parcel#
Address
Lot#
e Lx
Telephone#
Installer's Name r
b% eti
Designer's Name
Address
11/r G
Address
Telephone#
Telephone#
Type of Building 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) gpd Calc ated design flow Design flow provided gpd
Plan: Date /Um of she s Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name o Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS /` /' / Gil
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 p�e the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed lAZ 1-7, , Date
r
Inspections
No. —411/
Description of Work:
The undersign hei
by:.
at
has been installed
application No. OU
Installer
Designer:
No.
COMMONWEALT14 Of � 7 FEE
SETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ❑ Complete System
Eby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
acc r an e with the pyovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated . Approved Design Flow `-'%gpd)
Inspector:
Date: er `f / G'4/
as designed.
FEE ._
COMMONWEALTH OF MASSACHUSETTS.
Board of Health,�vl�f /, MA.
DISPOSAL, SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repairpgrade( ..) Abandon( ) an individual sewage disposal system
at r % r p,/C L o %2�% �U �/M'" ► N as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within *h �fftthe date of this pern t. All to al on itions mus e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �� �� C1C]7oard of Health li-t