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HomeMy WebLinkAboutApp-Permit-Compliancei. No. FEE ✓ "' `� Board of Health, YARMOUTH HEALTH DEPT. MA D �1 5 /`-�� C.�/2 J ROUTE 28 APPLICATION FOR DISPOWYM&MRMUCTION-PERMIT Application for a Permit to Construct( ) Repair (V4/upgrade ( ) Abandon( ) - ❑ Complete System "dividual Components Location S (� Ze "p Owner's Name Map/Parcel# -79 5- Address Lot# R Z Telephone# Installer's Name 64#eLj + de �t� J• �, t3 6(X Designer's Name s G Address x -76 3 Address l ,- � Telephone# Q& V22 Telephone# d ? D ?2- 70 Z7 I K Ve 7 /63 Type of Building J Dwelling - No. of Bedrooms _ Other - Type of Building No. of persons Lot Size l & ��� sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required)J7 JJ gpd Calculated design flow Design flow provided gpd Plan: Date (o _ q - Z 00'7 Number of sheets f Revision Date Title 11 rL: /47-e I </"oo A d Description of Soil(s) -e- i%% Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Ct S f Jlct Y bo p % A— CA J I) - a ©k C3 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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �C—/ Date Jen - C %� Zee® 7 a; Inspections 'i No. 0 -7 — / OI COMMONWEALTH OF MASSACHUSETTS FEE l� ' Board of Health, A J`tn- rf' !i MA. CERTIFICATE Of COMPLIANCE Description of Work: IV -Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by:�d04-A.J', &a--CL4+"-I f G) LL,G at 9-^ %Ae 1-. yam, &uzz �>% N has been installed in�accordance with the provisions of 310 CMR 15.00 (Title 5) and the ap r ved design plans/as-built plans relating to application No. / % ,Ldated (46O 'C% �% Approved Design Flow ��/•� gpd) Installer J -p tG�'11 -*t ej t se Designer: (,tS1A L)&n) Inspector: C/j�-� 'l Date: '7 � '2- 0 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No -0 7- /?/ �ei� / /!lft S COMMONWEALTH OF MASSAC14USETTS Board of Health, vow eAp jfkl, MA. DISPOSAL SYSTE4 CONSTRUCTION PERMIT FEE JV ` ellV �W (V 7 z34 Permission is hereby granted to; Construct( ) Repair (1 Upgrade( ) Abandon( ) an individual sewage disposal system at IJP P A Zit M-oo i a,�) AA f ,, as described in the application for Disposal System Construction Permit No. o % /9-'/ , dated,. �/ d 7 Provided: Construction shall be completed withi: `' of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 6 '"e o Board of Health 7(/sem