HomeMy WebLinkAboutApp-Permit-ComplianceNo. * o YC47-473"1 Y FEE 65 t D
(-®MM®VWUA1TN ®f MAggA('U N,
RECEIVES YARMOUTH HEALTH btr•-ep"laC, aecjapT oF'iS
Board of Health, 11 d R0131E 2-3 , MA.059• VOIJE 04%8117
JUN f 9 2017APPLICATION FOP, DISPO§ftyMft WMtCTION PERMIT " wolv R-tve-y'
raEPaTPer t to Construct( ) Repaii-V Upgrade( ) Abandon( ) - ❑ Complete System T ,Individual Components
Location Re=n
Owner's Name aC=1Cjl
Map/Parcel#C?qAo
Address %
Lot#
Telephone#
Installer's Name S / S r
Designer's Name
AddressP
Address
Telephone# 7 _
Telephone#
Type of Building Vlrz�
Dwelling - No. of Bedroo
Other - Type of Building
Other Fixtures
Design Flow (min. required) 22,0 gpd Calculated design flow
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size. 42 acre -
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided -b gpd
Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS IRPmaye 4 r what� fox
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the proviiqg-ns of TITLE 5 and
further agrees to not to pl a the system in operation until a Certificate6Ala ompliance has been issued by the Bo of Health.
Signe i Date
Inspections
-- — -
No. i3Ut� y-7 �'FEE .�0
��V
Board of Health, YA(ZI%AO0 k MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ()�, Upgraded ( ), Abandoned ( )
by:
at
&W
has been installed 'n accord ce with the >rovisio s of.,UO 0 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. ! dated % % Approved Design Flow (gpd)
Installer r'l V `? P r1.P5 /
Designer: s Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ?Ok��C—1%'"ti73� 'f' I�-'t-1"S �NC^ FEE `t' a'�`QO
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( )
at
Repair Upgrade
Abandon( ) an individual sewage disposal system
f as described in the application for
Disposal System Construction Permit. No, dated �b P�
Provic�edi` Construction shall be completed within three years of the date of this.„ ier t. All local cond' 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin BostahMA. DateBoard of Health