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HomeMy WebLinkAboutApp-Permit-ComplianceNo. YARMOUTH HEALTH DEPT. COMMO)OWAOTV*F MASSACHUSETTS SO. YARMOUTH, MA O2dd4 Board of Health, , MA. FEE 9e. 40 ro.� ZZ2 J (37r_C.5APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 'a Owner's Name WA Map/Parcel# 3 a Address Lot# Telephone# Installer's Name Designer's Name :�(/��L��. �p 9 - Address Address Telephone# '132- S 706 Telephone# 47 7 Type of Building %Y c ,AA ftA I&A Lot Size sq. ft. Dwelling - No. of Bedrooms "1 Garbage grinder( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) P0 gpd Calculated design flow 4 O Design flow provided q 7q gpd Plan: Datel 1 0� ©f Number of sheets Revision Date 1 Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 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 not to place the sy em in operation until a Certificate o Compliance has been issued by the Board of Health. Signed Date 1161101 Inspections Y No.COMMONWEALT14 Of MASSACHUSETTS Board of Health, 1i^A 4d&& _, AfA. CKPITIF l� ATE OF COMPLIANCE FEE 0 Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (' ), Abandoned ( ) by: at Ij has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to application No. ©/z_ � � , dated - cp �/� . Approved -Des gn'Flow (gpd) Installer 1►_�t /s� �i. <` GIMI� Designer: UWX P A aamr, Inspector: 14 1, 1 A5//Z Date: 0 The issuance of this permit shall not be construed as a guarantee that the systemwillfunction as designed. No. v J O'r�FJL O FEE 1/f l COMMONWEALTH Of MASSACHUSETTS Board of Health, , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted ,o; Construct( ) Repairo Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for V Disposal System Construction Permit No. dated Provided: Construction shall be completed withinrJSrs of the date of this per 't. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 6/Board of Health