HomeMy WebLinkAboutApp-Permit-Compliance-No.� v FEEol,. pO
Board of Health,
YARMOUTH. H.�AI.TM PT. 11
1145, .::o:
APPLICATION FOR DISP®SAt S liSITIM"CONS'TRUCTIO1V PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade*) Abandon( ) -. 0 Complete System 50 Individual Components
Location f4AjJOwner's
Name
Map/Parcel#
Address L/o
Lot# S- aj
Telephone#
Installer's Name`/ •
Designer's Name S-
Address
Address S
Telephone# Sd
Telephone#
Type of Building Lot Size sq. ft.
'7 / &"
Dwelling - No. of Bedrooms Garbage grinder (Wo
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) �/ D gpd Calculated design flow 33o Design flow provided y�/I gpd
Plan: Date /0 12.0 /6 A Number of sheets Revision Date -,116 %1
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSJ .. Trdjjj(I �k+g6J .S��y�r ,4s'jm•,1�
l7'ti'T1�414iFcILL/�5��A
J 0 -
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 th system m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Lf-- /6 -- o /
r
inspections
No. COMMONWEALTH it'.titLTH ®f 1�llA'L.H�1JSETTS FEE ,�0. ��+✓'
�S�K
Board of Health, �T
-� `/ CERTIFICATE Of COMPLIANCE
Description of Work: l3Yindividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed k,), Repaired ( ), Upgraded �), Abandoned ( )
by: f . r j
at Vo A d. , -, .rJi..z, 6' v „t + A7— -
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 0L 2-2 2_', dated ;- -/6 -Q/ . Approved Design Flow 441 (gpd)
Installer
(Cel —,),S —,J./
Designer: tr1 i . , � �1��4 � � � Inspector: Date:
The issuance of this permit shall not be construed as aaguarantee that ti e system will function asAesigned.
No.�_ - -- FEE .-D .--
COMMONWEALTH OF MASSAC14USETTS
Board of Health,MA.
SYSTEM
iA CONSTRUCTION+, , , PERMIT
DISPOSAL
Permission is hereby granted to; Construct() Repair( ) Upgrade (X) Abandon( ) an individual sewage disposal system
at ��E ��,�q�t �e�- as described in the application for
Disposal System Construction Permit No. OI "' Z, Z , dated
Provided: Construction shall be completed
/within
�� three years of the date of thismit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 7 V ^ 0 / Board of Health 'V'-/