HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPS.,
�- 1 146 ROUTE 28 FEE 60
' No. - SO. YARMOUTH, MA 02664 �
COMMONWEALTH OF MASSAC14USETTS
FOP,
of Health, m �7 , MAT
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( Upgrad Abandon( ❑Complete System.,XIndividual Components
Location Q i
Owner's Name
Map/Parcel# ` _
Address l�
Lot# '77�p
Telephone#
Installer's Name a �t c—
Designer's Name / km -L-,
Address ) � ✓
Address
Telephone# ap lkf
Telephone# ..
Type of Building�Sot��. T� v� L 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)
Plan: Date
.Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated /design flow
Number of sheets
Design flow
Revision Date
Name of Soil Evaluator H-cJltiT—ti Date of Evaluation IhAj=
DESCRIPTION OF REPAIRS OR ALTERATIONSE.�
gpd
The undersigned agrees t installthe ab a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a te- 1 t eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date J ✓c�'%��i
r �
/t
Inspections
No. % FEE
'L.OMMONV'1' EALT14,O MASSACHUSETTS
Board of Health, , MA. 6�w coCEPITIFICAf Of COMPLIANCE
Description of Work: 0.Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded V Abandoned ( )
by: I�N1a-•CiAPE
at 04,b S(f 1 NG. e..—
.has
✓has been installed in ccordance with the p ovisions 10 CMR 15.00 (Title 5) and theappr ved design plans/as-built plans, relating to
application Noi�. dated `/ �' _ . Approved Design Flow
Installer /'/7 i t�.f%1� ie 'e7_ C_. n
Designer: I7l/N'fC`/� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that de system will function as designed.
No.
COMMONWLAL114 OF MASSACHUSETTS
Board of Health, a,v' VA o �%� ,, MA.
DISPOSAL SYSTE CONSTRUCTIONPERMIT
FEE 17V CSC
Permission is herebygranted to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at Q 0 S O'f (K,yl_f� � vim, n as described in the application for
11
Disposal System Construction Permit No. '?,f :2./ 6 , 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 `✓ _7 i g Board of Health