HomeMy WebLinkAboutApp-Permit-ComplianceC Q YARMOUTH HEALTH DEFT.
No. /V 1146 ROUTE 28 FEE
SO. YARMOUTH, MA 02004 a
COMMONWEALTH Of MASSACHUSETTS
Board of Health, , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair�Upgrade( ) Abandon( )-,;&7Complete System ❑ Individual Components
Location , 6V��
Owner's Name�Fer,6&�,,7-
Map/Parcel# ��
�1 �
Address a?
Lot# �'��
Telephone#
Installer's Name
Designer's Name / V"49
Address
�,r.�-
Address 15v j7- /IC
Telephone#
�� 3� .
Telephone# �/3 ,Z j
Type of Building t .5! YETI a Lot Size sq. ft.
Dwelling - No. of Bedrooms .3 Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures y�
Design Flow (min. required) gpd Calculated design flow Design flow provided ✓, gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil(s)
oil Evaluator Form No. Name of Soil Evaluator�ll�J'� Date of Evaluation l �y`
DESCRIPTION OF REPAIRS OR ALTERATIONS 62tO
The undersi agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e ton aA�ystemn operation until a Certificate of Compliance has been issued by the Board of Health.Signe � Date
Inspections
No. l U 'l.®l�lll` O V'Vr X 1111 O MASSAC14IJSETTS FEE 9
Ate, a � ��
Board of Health, 0//Fi - �i'l�'/7'� MA. �' /�? Dl/
CER11FICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) P -Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaire�L• Upgraded ( Abandoned( )
at
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. "! a» A -dated Approved Design Flow 33 (gpd)
Installer
Designer: %>- /y101 -S 52N/ Inspector: ✓i Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
,,.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, L�/1"1G/1lGti/� MA.
DISPOSAL S STLM CONSTRUCTION PERMIT
--70
FEE -
Permission is hereby granted to; Construct() Repair( ) Upgrad'p�o) Abandon( ) an individual sewage disposal system
at �' �/VlJY�%� ���r 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 permit. All local conditions be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date`-- dol Board of Health