HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. -310 1146 ROUTE 28 FEE S
SO. YARMOUTH MA26
COMMONWEALTH OF THUSETTS
Board of Health,�T , MA.
APPLICATIONFOP DISPOSAL SYSTEM CONSTRUCTIO PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location /6
�!/G% Q l/(J,
Owner's Name
K'e V t tJ
C b
Map/Parcel# �?
.. % �D� ,
Address 17
Lot# isis
Telephone#
Installer's/Name
Designer's Name
�o n +t -e r
�► ,
Address
350 Main Street
Address
Telephone#
W. Yarmouth, MA 02673
Telephone#
4j 7 -
8 Q % 8
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) _
Plan: Date 9 -ds - t
Title � p le,
Description of Soil(s)
Soil Evaluator Form No.
A,e S
$ 3 d gpd Calculated design flow
Number of sheets - I
-e i
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS :G r lz) 1, 4,-f/
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided Y3, 7 gpd
Revision Date ,Z x?
Date of Evaluation
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 plac the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date S --off J-- 0
a
Inspections
E
No.y(J — �/U 'L_ OMMO WVIT 4 Of MASSACHUSETTS FEE �J U
Board of Health, NM_ OU l MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (u,KUpgraded ( ), Abandoned ( )
by: �'/9ti c- v
at 169 .S�i �U / % /,' G � •
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. 0 dated ` S OApproved Design Flow -3 a 7(gpd)
Installer % ./fin%l0 /I _
Designer:'aJ.4&A," l7U'/(/ZZ'/(f Inspector: Date: V -G' f vy
The issuance of this permit shall not be construed as a guara. ee that thsystem will function as designed.
No. FEE SO
COMMONWEALTH Of MASSA( 14LJ�T SETTS �
Board o Health, XV 84 ou >4 f1 , MA. � C"`
A
.f
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair(1,,)"Upgrade ( ) Abandon( ) an individual sewage disposal system
at Xq f sen . as described in the application for
Disposal System Construction Permit No. dated 6' - s -,5;v
Provided: Construction shall be completed within-th ars of the date of this permi All local conditions mustbemet.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date V - _ (Uoard of Health ✓