HomeMy WebLinkAboutApp-Permit-ComplianceNo. Bots-(� �Z��,13
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�OMMONWEALTH F MASSAC14USETTS
YARMOUTH HEALTH DEPT.
Board of HealiN46 , MA.
APPLICATION FOP, DIS � PMTTR CTION PERMIT
Application for a Permit to ConstructVRepair( ) Upgrade( ) Abandon( ) - R16omplete System ❑ Individual Components
Location F jo COAT
Owner's Name v r
Map/Parcel#F P g�L
Address C 1' AM s', ll,
Lot# c3 C
Telephone# Cso, �
Installer's Name a. 1 SSL[
Designer's Name t ��
Address c, ----
Address B 0 t
Tele hone#
Tele hone# /
Type of Building l? Q 56Cn.4)y4-R . Lot Size oTf%. 9 sq. ft.
Dwelling - No. of Bedrooms �OLJ4 Garbage grinder Ajo
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) /J t% gpd Calculated design flow�1 y e Design flow provided gpd
Plan: Date .5'-- 9-5---- /17 Number of sheets Revision Date -S--,k'9
Title
Description of Soils) 6-2 4/S /c7 -✓�� � l��S';3�-�� � �-a�S r� � y 'C/s 99-��a���l /�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
•uJ. W! CoX
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 agr s to not to place the system operation until a Certificate of Compliance has been issued by the Board of Health.
Signed M �(����V_, 'Date
v
Inspections
FEE �� 00
COMMONWEALTH Off' MASSA u �E M �' _4 � 222-
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Board of Health, T 1G wi c', e.?T /y ��c� I , MA. �
C ERTIFICAT ®F COMPLIANCE
Description of Work: 0 Individual Component(s) aleomplete System
7--17
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned O ��
by: r I`1,
at 9 (7-1 zT
has been installed in accoKdartce with the rovisions o 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to,
application No. � % dated �•� ^ % . A proved Design Flow i4r, Y -er'-4gpd)
Installer . C C.1 Q.� 1SS(,,,,.1
Designer: N 11vt3.1) 1 r�� "Inspector: Date: 5
The issuance of this vermit shall not be construed as „a guarantee that theKystemwill function as designed.,: 1 : r
No. V Ct `J ' `1 . r ` b c_ Y, FEE . 00
COMMONWEALTH OF MASSACHU�ETTS
Board of Health, Vi9l g (rte-- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(h') Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at PR C,_!tf 7-/.��. /✓ e :.EJ .S : � L4 51 1/, as described in the application for
Disposal System Construction Permit No. -, dated ,r .�
Provided: Construction shall be completedwithin tlir^y&'s of the date of this per m/it�!`j 1 local c ja 'ons must be met.
Form/ 1255 Rev. 5/96 A.M. Sulkin Co. Boston A Date
lr — �"` / ` Board of Health
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