HomeMy WebLinkAboutApp-Permit-Compliance1� YARMOUTH HEALTH DEPT.
No.jU 1146 ROUTE 28
r . SO. YARMOUTH MA 02
C®MM®N�LT14®F MAS 02 SETTS
Board of Health, �Y, !' `— MA.
FEE
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
c(U C V (r'�
Owner's Name
Map/Parcel#
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Address Q 3 e
Lot# (Cl
Telephone# 3 �,
Installer's Name
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Designer's Name��-�3�������t��
Address • /
-~ �c e
Address
Telephone#
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Telephone# Z, L__
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Type of Building /p�f /�� JCd� 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 Calculated design flow Design flow provided -3 �` ✓ gpd
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Plan: Date c, v 1 2- 'r Number of sheets l Revision Date
Title
Description of Soil(s) L /`G 2=Z
Soil Evaluator Form No. Y- 2 6e Name of Soil Evaluator -7�-:9 Date
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 agrees to not to place the6tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ i A a t_�� :1 ��r 6, Date
s ,
Inspections
No. ./-T FEE ty '
Board of Health, lOTi MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) IQ Complete System
The undersign,eo hereby certify that the Sewage Disposal System; Constructed ), Repaired ( ), Upgraded ( ), Abandoned (
by. r L
at 7 t_ IAZI
has been installed in accord a ce with the rovisi ns of 10 CMR 15.00 (Title 5) and the app ved design plans/as-built plans relating to
application No. Z/ ,,rd�ted// — Approved Design Flo l/. (gpd)
Installer %� %k1 L•- / 1 1S1SZ_/ 6_
Designee > . (.6�1-f'— c �✓��- Inspector:
Theissuance of this permit shall not be construed as a gudra
No.
Permission is hereby
L Date•"�°_tZ
t the system will function as designed.
COMMONWEALTH OF MASSAC14USETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
to; Construct(�j R�e^pa�ir( ) Upgrade( ) Abandon( ) an individual sewage disposal system.
at AT Ii/ / as described in the application for
Disposal System Construction Permit No. tQ2 — dated 7� �—
Provided: Construction shall be completed within-4wee-7eTrrs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date oard of Health