HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
-No.. ! v - ' 1146 ROUTE 28 FEE
SO. YARMOUTH, MA MON A P��^"-1
Board of Health, �T .
APPLICATIO�T FOP, DISPOSAL
L S ll �T STEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
VK) wner's Name
/Q
Map/Parcel#
�,6, SPO7
AC,Address
L®t#
-
Telephone#
Installer's Name
Designer's NameAt
Address
Address 3 5
Telephone#
CS -C) C7.__..
„ /�y�_ Telephone#
r�-
a�L
Type of Building ,/ZP�n Lot Size /.3 -740 sq. ft.
Dwelling - No. of Bedrooms d/d� /t e Garbage grinder A/V
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 gpd Calculated design flow— Design flow provided'gI'u
Plan: Date `-Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
6
Name of Soil
Date 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 e e sys mo a Certificate o ompliance has been issued by the Board of Health.
Signed Date
Inspections
No. 9e -37A FEE �-U
COMMONWEALTH Of MASSAC14USETTS
Board of Health-,• 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: j
at i� L, --
has been installed i accordance with the provisions of 310 CMR A5.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated
Approved Design Flow (gpd)
Installer - ' r 1J i2, 1
Designer: dVeQ. Inspector: ate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. V /) FEE
COMMO-NWILALT14 Of MASSACHUSETTS JT
Board of Health, MA. d V
DISPOSAL SYSTE4'CONST'RUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgr de ( ) Abandon ( ) an individual sewage dispos stem '
at /L Ut1C.; as described in the application for
Disposal System Construction Permit No. '78 - 3 V� , date 4 o
Provided: Construction shall be completed within three years of the date oft is per it All local con tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �G �� Board of Health