HomeMy WebLinkAboutApp-Permit-ComplianceNo. !/I f �✓ iFEE �
MMONWEALTH Of MASSACHUSETTS
00/, t- /c- �/, "� YARMOUTH HEALTH DEPT.
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!9014
40 5 Board of Health, 114 6 RQUTC 09 , MA.
APPLICATION FOR DISPO9R11"M'WMUCTION PERMIT
Application for a Permit to Construct (/Repair( ) Upgrade( ) Abandon( ) - LI Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
0
Address I ft
Lot#-
L 7 az-l/
Telephone#
Installer's Name
i� �� l�L
Designer's Name t) &- } MS
Address
Address IU4S a "• O*o1
Telephone#
S� /2.2F -p qL�
Telephone# '�.'L'� �•'�
Type of Building -Z;) V
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) /j 0 gpd Calculated design flow .�v Design flow provided 33"3 : D gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS�i� �_ i _ r 1�- �r � 1-5-60 6-c—, dl t s — A&,t
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 placea syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date - D
Inspections
No. !O FEE
C®MMO[ WEA LTH OF MASSAC14USETTS
Board of Health 'jp MA.
CERTIFICATE,-. OVCOMPIIANCE
Description of Work: ❑ Individual Component(s) Ooi mplete"System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: -ASCI
at r. //f JQ>! �--- --t 1 =rte' _tom
has been installed in accordance with the provisions of 310 CMR 15.00�(Title5) and the approved design plans/as-built plans relating to
application No. 6I -2 dated /%' / Approved Design Flow 3 S (gpd)
Installer E.c k + /
Desi ner: ,,. &jj IT C( roC Inspector ,. � �' 1 Date:
The issuance of this permit shall not be construed as a guarantee that the system will`funtction as designed.
No. / ) - — - C 1 ----:, FEE
COMMONWEAETH OF MAS 14USEITS,-,
Board of Health, Ad , le � MA / 3
DISPOSAL SYSTEM CDNSTRUCTI PERMIT
--2 AC,c%1, T ;
( ) ( ) 1 '
Permission is hereby granted to; Construct , Repair Upgrade rade Abandon ( ) an individual sewage disposal system ,,..
at `- `Yi? j`"` =tt *�• ',° - _li,Ajfr s A as.described in the application for
Disposal System Construction Permit No.O, dated
Provided: Construction shall be completed wi"thin tl 6. c.Zxs of the date of this peWmit. All lo•ca conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date6 / / Board of Health
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