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HomeMy WebLinkAboutApp-Permit-ComplianceNo. t!Z1y FEE �O � COMMONWEALT14 OF MASSAC14USETTS YARMOUTH HEALTH DT. Board of Health,1146 ROUTE 28 ,APPLICATION FOP, DISPOTRLYMPRMA�TWCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 33L4 n Liz 4 14 po Owner's Name s Map/Parcel# % ¢ Address Lot# Telephone# a - F'5 0l Installer's Name M[. (ks 6ro un4cs Co,,? 0 Designer's Name re) d C� Addressc 3 " -W 0ress Add ,- �,,� �� �' ,� �✓t Telephone# a Telephone# 3 �—, 5-- a 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) !ffo gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) on Soil Evaluator Form No. Name(7f Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS C) -&-4 �5 P n o-) ^C r) I --� ✓i - The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and Furth `�eesto p the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed � Date ©Z - Inspections No. - _ FEE COMMONWEALTH Of MASSAC14US ETTS � Board of Health, % rti^� ° ✓W MA C y` CEPITI ICA E OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded O, Abandoned O by. at tf!n L,fl �.' bn'�C—a 1 cl r has been installed in acco dice with the provisions of 310 CMR 15.00 (Title 5 and the p roved design plans/as-built plans relating to application No. 4/7 dated Approved Design Flow (gpd) Installer Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system ' fun tion as designed. i No. 692 4r --7--f— FEE ti✓ '~ COMMONWEALTH OF MASSACHUSETTS 77(0 Board of Health, DISPOSAL SYSTE '1[ _ ONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at 3 � G Lin o1 r tvAc `�) 0` � �' �� as described in the application for Disposal System Construction Permit No. Q� dated., " Provided: Construction shall be completed within e date of this permit. All local conditions X4ustbe met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ��� Board of Health J C �l(��'�✓ i