HomeMy WebLinkAboutApp-Permit-ComplianceNo. [/ 7 �u�� r���lGl• 1 FEE ID . OC)
Board of Health, YARMOUTH HEALTH DENPAT.
1140 HOW E 28
A PLICATION FOP, DISPO9,%1yNV5",M6AWUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (�Abandon( ) - ❑ Complete System ❑ Individual Components
Location r
p, S t ��( �, ,� R/1itd
Owner's Name i ��� /loop f-
Map/Parcel#O-16
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Address /�(Q, n 5 5 � FO g- S M�
Lot# Li I
Telephone# 1 — q 7$- Zyi ., y 9 & 2
Installer's Name
6e, -T Z. oo a C,-),
Designer's Name �� k:5 (,-OC-P-
Address P 09 Bo*
i-!2 14G-Cu)►C,�n /��'i-, QZ% J`'
Address `!.�, a0?L 144 s, Ibe,,n-.5 ii2to60
Telephone# 'Z -o530
Telephone# T6F- 3 $' 9,311
Type of Building 9 o i a e^ T-1 a Lot Size 1,3 coo sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ?j 3 Q gpd Calculated design flow Design flow provided 3 3 f gpd
Plan: Date Z� 13 OLI Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator b "J Date of Evaluation 10'Z6 - O LI
DESCRIPTION OF REPAIRS OR ALTERATIONS I Soo 5,i, 100 a -P � � 1-i H -16 &P 1 n - 1 T�'C�`�f / ^
Jo'x 37 `x l o Wet i
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to note to place the system in o er tion until 'Certificate of Compliance has been issued by the Board of Health.
Signed �,.tejce
�J >01J/9�CR /Date
'Inspections 3A � G ✓� i G-
t%O_ c 3
4 'U —a' S 7ar*,,a walla"
- f f
No.
COMMONWEALTH OF MASSACHUSETT�,,/
Board of Health,� KMO 011, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 4dltomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: P 4j V e T Cy N� Co.
at '?7 =Y, uutu > 73I vd
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. l% (i� �i dated Z ` iJ Approved Design Flow (gpd)
P-0 Installer Pt)%r--r 13 OyVa,Co. f1 y
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guar tee tdat the system will function as designed.
No. 6 CJU - -- — FEE -
COMMONWEALTH Of MASSAC14USETTS
` Board of Health, \1 A 4,11'0 U 1 1, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (%) Abandon( ) an individual sewage disposal system
at 9 7 u i S , y as described in the application for
Disposal System Construction Permit No. ,�q 6/-/'T dated2- �� 5
Provided: Construction shall be completed withinrsl the date of th-p�rmit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Da ez Board of Health
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