HomeMy WebLinkAboutApp-Permit-ComplianceFEE I v -'
OMMONWEALWR(YON4QgW�&4S
Board of Health, 1146 ROUTE 28 MA.
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SO. YARMOUTH MA 02664
1.0// APPLICATION FOP DISPOSAL. SYSTEM CONSTRUCTION P ERM11
Application for a Permit to Construct( ) Repair (t4 --Upgrade ( ) Abandon( ) - ❑ Complete System ❑ Individual Components
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Locations /
Owner's Name
v� 2 O>rGC
Map/Parcel#
Address
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Lot# �9
Telephone#
Installer's Name
Designer's Name
Address
Address
Telephone# W. Yarmouth, MA 02673
Telephone#
Type of Building V<Q Z— • Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 15 �3D gpd Calculated design flow _3 36 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title t 1R
Description of Soil(s) AeA P (d,)
Soil Evaluator Form No. Name of Soil Evaluator / Date of Evaluation
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 plac the tem in operation until a Certificate ofCompliancehas been issued by the Board of Health.
Signed Date d3 `Q -D
i Inspections y `l _ U� 924�622
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No.COMMON` V'V' EALT14 OF MASSAC14USETTS FEE
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Board of Health, �� ( oJr �\
CERTIFICATE Of COMPLIANCE
tion ) of Work: ❑ Individual Com onent s ❑ Complete System
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Description P ( p y
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (t4 -,Upgraded ( ), Abandoned ( )
by: C-q�C�m�
C� -Q1SfP_� u. ox
at /110 )'JJ4 2_S /,.l ,,1 0 . S _Un �,
has been installed in accordance with the rovisio4ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. JV-" dated Approved Design Flow J14 (gpd)
Installer
Designer: 0-1n F/1(,,r-//VFZt Z/ -,Lt& 'spector: �Date: _
The issuance of this permit shall not be construed as a guarantee that the, system will function as designed.
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COMMONWEALTH AF MASSACHUSETTS
ASSACHUSETTS
Board of Health, f C(,4 A d ✓A , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
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Permission is hereby granted to; Construct( ) Repair(�f//Upgrade ( ) Abandon,( ) an individual sewage disposal system
at _16) /) �a � 1' 1f# 1U.,f . -. ,YCu1ri► as described in the application for
Disposal System Construction Permit No. '�-�, dated
Provided: Construction shall be completed within thTee-pc-rrs of the date of this permit. All local conditions must be met.
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/ Form 1255 Rev. 5/96 A. M. Sulkin Co. Boston, MA Dat —.2-q_60 Board of Health di