HomeMy WebLinkAboutApp-Permit-ComplianceYAHMVU I H HLALI H ULF 1
11.46 ROUTE 28 FEE�vO
Y SO. YARMOUTH, MA 02684
®MM®lNWEALTH OF MASSACH S
CG�7 rd of Health,
A�A/fy AP PLICATI01 ®R. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permitxo Construct() Repair( ) Upgrade( ) Abandon() ❑ Complete System ❑ Individual Comp one is
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Location ZVy
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Owner's Name
4 J t j �ry S
Map/Parcel#
C.` — y
Address
s 7�
Lot#
Telephone# C k_ 77/_ ,Z W 7
Installer's Name
Designer's Designer's Name
K Ly
Address
A elf
14
Address
Telephone#
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Telephone#
Type of Building /'as/ / X,,,,;z-` 4WO cc Lot Size �� 7z 0 sq. t.
Dwelling - No. of Bedrooms Z Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 i*O gpd Calculated design flow Design flow provided -7 gpd
Plan: Date ����—�% Number of sheets ! Revision Date
Title _ bPj4-7/1 .S`a /
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed // i Date
Inspections
COMMO ALT14 OF 1�IASSAC14USETTS FEE
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Board of Health, gIL2AQ�2b MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) El Complete System
The undersigned hereby certify that the Sewage
Sewage Disposal Syste Constructed ( ), epaired ( ), Upgraded ( ), Abandoned
by: e ( N V ( S SU
C 1/j '^"
at LOT t-1 FAIR -000b _ P-0 A7 .S'Y
has been installeccor nce with the provisions of 310 CMR 15.00 (Title 5) and roved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
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Installer
Designer: /r/9Sr/%t'Inspector: k Dater Iaf/�I
The issuance of this pP ermit shall not be construed as a arantee that e system will function as designed
_ � � Ys
No. �� �� FEE
Board of Health, ( PVI D 0-1-7'f' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;onstruct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
S
Disposal System Construction Permit No. , dated ,? /,
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 00 oard of Health s C_ �-� ✓ ` -,