HomeMy WebLinkAboutApp-Permit-Compliancea
sy C®MMONW� A LTB O F' MASSAC14USETTS
FEE
Board of Health, YARMOUTH HEALTKZEPT.
11414WEAW�W
APPLICATION FOP, DISPOSALcg) ION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade /(AbandonV ❑ Complete System ,Individual Components
Locationyv,
Owner's Name J, r
Map/Parcel# I b
Address r ,2_c,) /j
Lot#
Telephone#
Installer's Name t ,j t
Designer's Name
Address ° 7Gfi+i'4is,
Address �� r YYl��
Telephone# p C7 'jr
Telephone#_,4Z&7? IP
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow �� Design flow provided gpd
Plan: CDate ii11 12,/ 1 0O 1 p1 Number of sheens I ! Revision Date
�/ -•�-
Title J,T PI n,.,_ M ..1 \ �� Ln -r J� 14 � JGI J � Vi2 rfUIVIA DELI tb A
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
— f I - - /'
Name of Soil Evaluator 1IAAL Date of Evaluation 1 ZZ
.aA ,� AA41d +
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 tplace the sys in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ./��M 'j�Lt'��,p' Date
' Inspections
No. sb 3 COMMONWEALTH OF MASSACHUSETTS
FEE 5V � CJ
Board of Health, t��m t9l Awl.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned/
r A r- 1'r 11
by: 11 1
at IQ 6 If
has been installed in a
application No, -&V —
f
with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated / _ —'— Approved Design Flow - - (gpd)
Installer Oe
Designer: 0C . ,:g�f ( 12f Inspector: ;X2
The issuance of this permit shall not be construed as a guarantee that
Date: 12-6-M
ie system will function as designed.
FEE_
COMMONWEALT14 Or MASSACHUSETTS
Board of Health, *(M(9J1 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is kXebX g(atlted to -Con !Zuct( �_ • R(aif:(, �. Upgrade Abandon an individual sewage disposal system
at !! �� �V "-0 M )O ''r as described in the application for
Disposal System Construction Permit No., dated 12—S-66
Provided: Construction shall be completed withins of the date of this perm'i . All local co ditions must e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
J