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HomeMy WebLinkAboutApp-Permit-CompliancewN '-8014X _1"" 35 �S FEES 00 7- COMMONWEALTH Of MASSACHUSETTS YARMOUTH HEALTH. DEPT. Board of H1rL l ; 'Uealth, 1146 ROUTE 28 T , MA. APPLICATIO�T FOP, DISPOSK MgWCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑ Individual Components Location A j EAS' ATi4 Owner's Name TOW4 Map/Parcel# jL19L.0 20129 Address 21 0AVEX$:P&T14 ©&T145p0-94I1 06TA Lot# Telephone# Installer's Name CA PCW iDE EPSzg Designer's Name 014 - Address 153 d4,U CB -,+C t t'W 40 Address Telephone# 502 -if 77 .. �-?'? Telephone# Type of Building R Lot Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) _ Soil Evaluator Form No. sq. ft. Garbage grinder ( ) Showers( ), Cafeteria ( ) gpd Calculated design flow Design flow provided Number of sheets Revision Date Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS -T )v tzii u Pak) 14-16 V (?L)K L L114 PJ — gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees ton place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 3- zot- Inspections No. � G H l�C -I � 355_ PO', FEE COMMONWEALTH OF MASSACHUSETTS / / Board of Health., i k P -M 0 V I4 , MA. O\f-- riz CERTIFICATE Of COMPLIANCE Description of Work: Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (A, Upgraded ( ), Abandoned ( ) by: (Mioew 1 bg GJT&-XPAl«, at -21 A49,CV3 D/t714 _5>0077-( 0-04'0 a7764 has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. �/ , dated _�4 Approved Design Flow — (gpd) Installer ° V L Designer: NZA.. Inspector: Date: ----The issuance -of this -permit shall not be construed as a guarantee that the system will function as designed. No. � 7 'J POW 11) C— FEE COMMONWFALTH Of MASSACHUSETTS ck--�07?3q Board of Health, l Yl D V14 , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(x) Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. % - g dated,/,��j_ Provided: Construction shall be completed within s o" "f iiielte of this permit. All local conditions must be met. YForm 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date 7 i7 Board of Health