HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. 1146_ROLITE 28 FEE
YAR MOUTH, MA 02664
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kh2c9TiO92 Board of Health, , MA.
AFIPLICATION FOR DISPO�AL SYSTEM CONSTRUCTION PERM[lJ
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
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Location �/ •- �j_�
Owner's Name
Map/Parcel#
Address 1 `C� -eY
Lot# --V- 2-1
Telephone# S
Installer's Name �` 6�i/Lc��J
Designer's Name��-G.� L2
Address
Address Z !--1� f
Telephone#,:5'
Telephone# `:50-9
Type of Building ^ Lot Size 7 73 V sq. ft.
Dwelling _ No. of Bedrooms Garbage grinder Jr -*W
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) y gpd Calculated design flow 3 �/ �? Design flow provided ?-7 4' gpd
Plan: Date% --- � Number of sheets I/ Revision Date
Title e/ fele A41'--) 7W
Description of Soil(s)
Soil EvaluatorZorm No. Name of Soil Evah tor��s� to of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS 7��V
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreec th�'eration until a Certificate of Compliance has been issued by the Board of Health.
Signed '�DateC2-7—
Inspections
No.� FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
OF
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in ccordance with the provisions of 3 0 CM1�15.00 (Title 5) and the a}�proved desig'hkplans/as-built plans relating to
application No. - ,, dated -Z2�_ Approved Design Flo , 3 3/. '7gpd)
Installer
Designer:., �li✓GG Inspector: '� Date:
The issuance of this permit shall not be construed as a guarantee that a system will.function as designed.
No.� FEE J
COMMONWEALTH Of MASSAC14USETTS
f
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an`individual sewage disposal system
at/ 1q t���=c as described in the application for
Disposal System Construction Permit No. / `7 dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date % Board of health V
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