HomeMy WebLinkAboutApp-Permit-ComplianceNo.
YARMOUTH HEALTH DEPT.
1146 ROUTE 26
COMM0 • AC
Board of Health,
r.>--�%6
APPLICATION FOP, DISPOSAI SYSTEM CONSTRUCT11
Application for a Permit to Construct( ) Repair( ) Upgrade (6e bandon( ) - aelm-,Plete System
5'0
❑ Individual Components t ltaeL4
Location 39
Owner's Name
Map/Parcel- G 7 —11616,1/VArx/
Address C
Lot# / Z
Telephone#
Installer's Name
Designer's Name
Address
C p S 13 F P.O. e)oX 178 0 1 A d e s
Telephone#�.
(o , — Telephone# 3 9
LND--Oy L
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) 33a gpd Calculated design flow Design flow provided 3 `S�• gpd
Plan: Date la(, Number of sheets r Revision Date
Title
Description of Soil(s)�L�l:
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
V.
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 agrees to nottoplace the cyst in operation until a Certificate of Compliance has been issued by the Board of Health.
Sigmed 01 p�G.A��� ' C, �<�1� Date
Ins�,ections ��
No:/ /
�Y f ♦ /
COMMONWEALTH Of MASSACHUSETTS FEE
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Compgnent(s) Q Complete System C--/
The under'gned hereby certify f the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (47,�Abandoned ( )
by: ,
at � � n F-1at31nPot?, _
has been installed 'n accordance with the, jrovisions of 31 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. > ed T _ ` % Approved Design Flow 3 -57(gpd)
InstallerDI
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that &e system will function as designed.
No. 77 I ar v �.- �` „'' /�c�j/� E^ FEE
Board of Health, _LAffi,AV5--� MA.
OISPOSAL SYSTEM CONSTRUCTION PERMIT *r
Permission is here,,lZy granted to; Construct( ) Repair( ) Upgrade (1-1" Abandon( ) an individual sewage dis osal system
at
as described in the application for
v t
Disposal ,System Construction Permit No.- , dated "�`-27
Provided: Construction shall be completed within three years of the date o this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dateoard of Health