HomeMy WebLinkAboutApp-Permit-ComplianceFEE /
No. C/.
/71-,�,4%0i%C�-COMMON LTH Off' I�' ASSAC14US ETTS � 4.# /�
A&A-7rT U/ � YARMOUTH HEALTH DEPT. 1 `�
Board of Health, U ea Q� �.OUT-E28 , MA.
APPLICATION FOP DISPO- rfflfffJCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location -7 %;�A Q C "'
Owner's Name 5 .�
Map/Parcel# ?1? 1 (o-0
Address S „�
Lot# (4;cj 6J-P%i dl
Telephone#
Installer's Name �� �.� �,�
Designer's Name oS
Address- ��� S S y
Address5 S`
Telephone# '.,;p
Telephone#
Type of Building `L --,Z t iA (- 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) �v �� gpd Calculated design flow`) Design flow provided '1 gpd
Plan: Date 3 acl- CID Number of sheets , Revision Date
Title --::z, "E (1p
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluatory Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I�� AV, -
The undersigned agrees to install the Bove described In ' 'dual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur em m oper a Certificate tof�Co/mplian-cye has been issued by the Board of Health.
Signed Date 7 " / t C� iaG/
Inspections
No. Od CO MONWLA T14 OF MASSACHUSETTS FEE
Board of Health, MA. /,
CERTIFICAh'OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Womplete System i-0///0
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( , Abandoned ( )
by: X11 S�cQ��L t
at —T Z CA 0A i AV`J G1�V45F_ �Gc ��C�•- {A�ZiAiln �
has been installed �in-yaccordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. (/C/ ^�� dated Approved Design Flowpd)
Installer
Designer: �Oy/C� /�H//f/i' ___ Inspector: Date:
The issuance of this permit shall riot be construed as a guarantee that a system will function as designed.
�J
No. l/ � �/j� L ✓�j�� G c- � �%�.___ FEE
COMMONWEALTH OF MASSAC14USETTS �Dcl �� �--W
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (Lw.�Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. 6 z,V dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All 1 c gondition� ust be met.
,� �) 1 ''
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health