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HomeMy WebLinkAboutApp-Permit-ComplianceFEE CjY COMMONWEALTH OF MASSACHUSETTS YARMOUTH HEAD. i r=.: _ - Board of Health, 1146 ROUTE 98 , MA. APPLICATION FOP, DIS4%'RV?0'rW1RUCTION PERMI1 Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 4:1 Owner's Name („11AA tJ4 1q OF 41,*N -` c Map/Parcel# .3 ©d �UL a tJ Address 3VO we-v-�5 �N+T .�� Lot# 6LWV Telephone# Installer's Name C.t Designer's Name A Address 153 (Q -,S—, 4S�&E Address Telephone# 5&F - 4 77 -- E 95 -7-7 Telephone# Type of Building —rf 4=c co X.77) p Lot Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation gpd DESCRIPTION OF REPAIRS OR ALTERATIONS REf LAe.+� - 4-Is—)6— ff-" U4 ®-P -rL, 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 t Jace the system in operation until a Certificate of Comp 'ance has been issued by the Board of Health. Signed ' Date 7,0 r Inspections No. COMMONWEALTH OF MASSACHUSETTS .1, e o Board of Health, \1A xc )U T14 , MA.,A�,�C/v,f - 0 " IWO CERTIFICATE Of COMPLIANCE W -11f FEE + Description of Work: ❑ Individual Component(s) ❑ Complete System / The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (X11 Upgraded( ), Abandoned ( ) by: ��Pi� LtJ'i"�tQISS at 3 y () dy L., w t f :1 ©�'. __....__ has been installed in accorda ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. , dated 7 -.-?4—/' 7 Ap roved Design Flow (gpd) Installer�GrnQ�I Designer: t\j j Inspector: 4 ' ��� Date: 9'b7 The issuance of this permit shall not be construed as a guarante�e1 that the system will function as designed. No. �O%�yC-I�`C�O�CJ U"S�GW1�� !~1J�ZPS FEE.OQ COMMONWEALT14 Of MASSAC14USET TS Board of Health, / A y-'4 O u -(v4 I.. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at 300 U�. /t� -�-5 C. x�� -ab d_U C. Disposal System Construction Permit No. 7— �, dated �17 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 / " �/ / Board of Health %