HomeMy WebLinkAboutApp-Permit-ComplianceYAHMUUTH HEALTH DEPT.
No. �- 1146 ROUTE 28
70
SO. YARMOUTH, MA 02684
,�OMMONWFAI.114 Of MASSACHUSETTS
Board of Health, MA.
FEE J
APPLICATION FOP, DISPO I SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade((/Abandon() - ❑ Complete System ❑ Individual Components
LocationQZ '
Owner's Name
tap/Parcel#V
p
Address
Lot# Lt Z A66W
Telephone#
Installer's Name
Designer's Name
Address
Address
Telephone# co .�• ^ '�
Telephone# S:Pyo6
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms �� Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures �„
Design Flow (min. required) gpd Calculated design flow �� Design flow provided _33D,gpd
Plan: Date �(5 Number of sheets ft Revision Date
Title -LAI, Description of Soil(s)
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 snnot to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed /.% LLZ� ` �.Z5 ,(14pAdffh (Date 0 i� O
Inspections 4 -
No. � FEE
COMMONWLALT14 Of MASSACHUSETTS
Board of Health, MA. O,
Description of Work: ❑ Individual Component(s) ❑ Complete System
The unde signed hereby cerd at the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (L f, Abandoped ( )
by:
at
has been installed in accorG`n/ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. m -. 6jf , , dat 11; ^ipo Approved Design Flow
Installer
Designer: Inspecto : Date: 7
Zte-
The issuance of this permit shall not be construed as a guarantee tha a system will function as designed.
No. ICI FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereb granted to; Construct( Repair( ) Upgrade(L.?/Abandon( ) an individual sewage disposal system
at C as described in the application for
Disposal System Construction Permit No. eO dated 5 �O >
b kzm S
Provided: Construction shall be completed within t ears 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 ��' oard of Health �'