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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �� ' FE © W � YARMOUTH HEALTH DEPT. 'a-^ rd of Health, 1146—ROUTE 28 ALL. APPLICATION FOR DISPOIWIMMMAWGION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location%% Owner's Name Map/Parcel# Address Lot# Telephone# Installer's Name Designer's Name Address Address / Telephone# Tone#f. - XS Type of Building Dwelling - No. of Bedrooms Other - Type of Building Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) .3� gpd Calculated design flow 33-6 Design flow provided 337 gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agre o ce syste eration until a Certificate of Compliancehasbeen issued by the Board of Health. Signed Date A Inspections CIA No. Jl FE COMMONWEALT14 OF MASSACHUSETTS �-14 q�4 � Board of Health, Gv 9f MA. CERTI 'I E Of COMPLIANCE Description of `Mork: ❑ Individual Component(s) Complete System The undersjgVd hereby'tit the Sewage Disposal System; Constructed ( ), Repaired (�pgraded ( ), Abandoned ( ) by: a lz"/ rt atLZ has been installed in accordan e with the provisions of 310 CMR 15.00 (Title 5) and e ap roved design plans/as-built plans relating to application No. _ 5 , dated /d W. Approved Design Flow 3 (gpd) IInstaller d -x-. - 1�C a Designer: _ ._ Thp_issuance of this No. 6 — S //4 Permission is 'Inspector: 6 -YA Date: 11 f 00 shall not be construed as a guarantee that the system will function as designed. F COMMONWWT14 Of MASSACHUSETTS Board of Health, 1 1,$12 /%7A- , MA. DISPOSAL SYSTEM &NSTRUCTION PERMIT tted to; C,yonstruct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at �-5 iii// ULIT, A as described in the application for Disposal System Construction Permit No. ^ s�� , dated Provided: Construction shall be completed within t ,rn� of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �� _'�G UyBoard of Health /K2��V( A /Gi>1Ti?