HomeMy WebLinkAboutApp-Permit-ComplianceNo. `� l I FEE
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t�Urd� Board of YARMOUTH HEALTH DEPT. MA
4iU ROUTE 28 rh
APPLICATION FOP, DAMIWOMn"MSTRUCTION PERMrT
Aoplication for a Permit to Construct( ) Repair P
Upgrade( ) Abandon( ) - ❑ Complete System ,"dividual Components
Location
Owner's Name g
Map/Parcel# 12
Address
Lot#
Telephone#
Installer's Name J
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)�gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
3'
The orders' a agrees t install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e t Otto e m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date (4 2— — 08
Inspections jyda
No.
COMMONWEALTH Of M HUSETTS
Board of Health, MA.
Description of Work:
The un'devsiaxad het
by:
at
has been installed in
V
FEE
❑ �trHividual Components) L1 Complete System
by certify that the Sewage Disposal System; Constructed ( ), Repaired (�,1), Upgraded ( ), Abandoned ( )
with the provisions o 310 CMR 100 (Title 5) and the approved design plans/as-built plans relating to
dated (o . Approved Design Flow -SESgpd)
Installer/-' 1-- ' e'ifr°''17-111"l e
Designer: Inspector: > 0 u' (...k ,l:;t~Z Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. � /j,.�G �, ,fir FEE /CC'•
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, f r� € r :� dl's MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
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 Board of Health