HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28
No. 9SO. YARMOUTH, MA 02664 FEE
Board of Health,�T , MA.
APPLICATIONFOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - U Complete System U Individual Components
LocationA5%jQ00 OA -9—S.
Owner's Name
w c
Map/Parcel#
Addressa43
woof) - 5—WN,
Lot#
Telephone#
a 3�-
Installer's Name t v lc,"alDesigner's
Name
Y1A lP l"
Address) , ' Jl
11
Address
1 S
Telephone# �6 193
Telephone#
Type of Building R-4=3� /b!> "T�`�.. Lot Size sq. ft.
Dwelling - No. of Bedrooms 4— Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 44-0 gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) —
Soil Evaluator Form No.
Name of Soil Evaluator
1%
DESCRIPTION OF REPAIRS OR ALTERATIONS Ck64.,
Date of Evaluation
ko P
The unders ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further s n to �WV;777
in operation until a Certificate of omplice has been issued by the Board of Health.
Signed7, K.- ' Date
Inspections
No. , FEE
C®MM®NWEALTII Of MASSACHUSETTS
Board of Health, )A1 Bar !7 Mm.
CERTIFICATE Of COMPLIANCE
Description of Work: U Individual Component(s) Complete System
The undPro
' reby ertify that the Sewage isposal System; ,Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 'Cp t� l i�jv'�Y,/ ff
at , � o ) nl-jd. V(ymttit.
has been installed in accordance with the provisions of310CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. W ' : �, dated
I--> - `�U Approved Design Flow 4-100 (gpd)
Installer 'CpSI l� r Cwt �l L
Designer:% E�/�//�/EZ`— Inspector: Date: _
The issuance of this permit shall not be construed as a guarantee that the systenXill f
Inction as designed.
No.
C®MMONWFAITH Of MASSACHUSETTS
Board of Health, V/1W /het- 17-,Z MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
�MA
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade*-) Abandon ( ) an individual sewage disposal system
at (,{/`C/�,bi9 z� as described in the application for
Disposal System Construction Permit No. , dated 5 ` Z- -3 _ f F
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date `S'g Board of Health