HomeMy WebLinkAboutApp-Permit-ComplianceNo. IV) 4 FEE
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COMMONWEALTH OF MASSACHUSETTS (1[4+ 2�,�--3
�n��� Board o Health YARMOUTH HEA
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PPLICATION FOR DISPOSA AWWJ�JION PERMIT
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A plication f Permit to Construct( ) Repair( ) Upgrade( Abandon() - ❑ Complete System ❑ Individual Components
Location' d 4 7/i "W/Z-
Owner's Name Z, if g1te&,f AjlGl4vJiS
Map/Parcel# 7(l J
Address 3a tim-o mr Tf 22 cf� S ,.•1
Lot# 7� '/X 7
Telephone#
Installer's Name U `X ?�j
Designer's Name
Addres 92 6"'OGLV 5 P4
Address xj f `jZ407q— &J1i Srj l (Zo
Telephone#3f-5"--3-/63Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms G'�jCP1'1/ - Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided ggpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
The un
further
Signed
Inspect
Name of Soil Evaluator
Date of Evaluation
described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
in operation until a Certificate of mpliice has been issued by the Board of Health.
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FEE
Board of Health,MA.
CERTIFICATE Of COMPLIANCE ie�� ��.�,., c�� S011 �...
Description of Work: ❑ Individual Component(s) / Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (L—'/Abandoned,( )
by: o � J� 1 �a2 IL t4v /1 (..- . ,
at a5 Me A -e 6 W yAt,-o 16•TT-14
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. dated % - 2 Approved Design Flow(gpd)
Installer >} yL-Ct Z/`/ti�7 /� <m2r
Designer: Inspector:LZSri l t l + 6-M Date: /!g/
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. V 5<) G'/%v FEE
C®MMONWLALT14 OF MASSAC14USETTS
Board of Health, Y�L2 41eVL1,5-1 , MA.
DISPOSAL SYSTEM CONSTRU TION PERMIT
Permission is hereby granted to; Construct ( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at � Ll/'�,�f f�: / C �2 ��i G as described in the application for
Disposal System Construction Permit No. _ ��� , dated
—_-v„,ovided: Construction shall be completed within o -f the date of this permit. All local conditions must be met.
i1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date
Board of Health a
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