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HomeMy WebLinkAboutApp-Permit-ComplianceNo. YARMOUTH HEALTH DEPT. 80. YARMOUTH, MA 02664 Board of Health, , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION Application for a Permit to Construct( ) Repair (�rade( ) Abandon( ) - ❑ Complete System e FEE Ta - ccFE0VMED M AY 2 5 2001 I DEPT. lual Components Location �� S we p`� 2 � Owner's Name 2 Q ,, S {'�, '!\ 0 Map/Parcel# LlLq Address S u,- , Lot# Z Telephone# CI 9 _ a (o `2-'7 -Z- Installer's Installer's Name P ��M L Designer's Name Address 3 �� �� S ; Address Telephone# 7 i .� .' ©O Telephone# Type of Building tczx �5'i`� Lot Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS C��� �•e�L� �Y�c2i�v� �.�a� �v� gpd The undersigned agrees to ins a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr tD tlac the ystern in operation until a Certificate of Compliance has been issued by the Board of Health. Signed `� Date S ' v1.S' Inspections No. COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. FEE Description of Work:nC� h" vidual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,, �,pgaded ( ), Abandoned ( ) by: (\ � C o r,^ C d at 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. 0.1 7dated 7 /, Approved Design Flow (gpd) Installer 3 CCA/', O Designer: Inspector:4 Date: S ' Z 1 0 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. o l — Z -3 7 I FEE COMMONWEALTH Of MASSAC14USETTS Board of Health, "-) AC UY\Ou'� —,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at s k S,,-G..,,-���- �` �. V Ld c� cQ �-�c S l` ���t L ��lp 1 i�r� as described in the application for Disposal System Construction Permit No. dl--) 57, dated S-- Provided: Construction shall be completed within �f the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. SWkin Goo. Boston, MA Date "-� �� Board of Health / r/A/I,-^