HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH OF MASSACHUSETTS
v Board of Health, YARMOUTH HEALTH ISP'.
APPLICATION FOR DISP® AW , iqg)WWUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Q 0 1-4NF—
Owner's Name V, F, < j WWO
Map/Parcel#
3 �AL
Address
Lot#
Telephone#
Installer's Name
S /3 xOS
Designer's Name
Address
Address
Telephone#
(� -!� — 2-
Telephone#
Type of Building eJ E / // b/G Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 336 gpd Calculated design flow 330 Design flow provided �s7�. a1 gpd
Plan: Date 6 �Zd - Oz Number of sheets 19A) E— Revision Date
Title
Description of Soil(s) z
Soil Evaluator Form No. �i.5/pJ`— Name of Soil Evaluator %� U/%7�S Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ;PF-PLYgCe-
�E���Ci�/�
The undersi a agrees to ' e above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre t not to la a to pieration until a Certificatf Compliancy h/as been issued by the Board of Health.
Signed Date / 0 v
so
Inspections
I
i�150
No. FEE
COO V'V' �rALT14 ®F MASSACHUSETTS
�`lll`ll
Board of Health, ltit.Gy !/ f/OyC Cz 1�/i
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) Ll Complete System
The undersigned hereby cer 'fythat. the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded ( ), Abandoned ( )
by: re" ref cb'
at IVO p�
has been installed in accprdapce with the provisions of 310 CMR 15.00 (Title 5) and thea 'oved design plans/as-built plans relating to
application No.. Q Q dated ' e �s Approved Design Flow (gpd)
/�'
Installer j={� t 'S GC 1 /` G t "Ori l p
Designer: f 0f! Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that th16 system will function as designed.
No. FEE s
P—a�re'fl
Board of Health, %y't 0 MA. a/L/
7
DISPOSAL SYSA M CONSTRUCTION PERMIT
Permission is hereby �jgrrantted�tLo; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
VU at 1 13 /") LQ r) ��J > as described in the application for
Disposal System Construction Permit No. �� 47/ �, dated
Provided: Construction shall be completed within s of the date of this "it. 'All local conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ! k -a ->—Board of health`