HomeMy WebLinkAboutApp-Permit-ComplianceNo.� FEE
COMMONWEALTH OF MASSACHUSETTS
Board of THealth YARMOUTH HEAL ".tp l
APPLICATION FOP, DISPOSAMWTANSTEWION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade/Abandon(/j- Complete System ❑ Individual Components
Location I o CA,, N
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Owner's Name l, C
Map/Parcel# r7 7 "7 Z
IVj-jV
Address d C r
Lot# � 02- `>
Telephone# 3'i —Z 2 '
Installer's Name
6%.51-
Designer's Name
Address
! 5—�
r %�
Address d 0 ZSg rte
Telephone# -7
Telephone#
Type of Building Dwe l / e Lot Size I �o sq. ft.
Dwelling - No. of Bedrooms Garbage grinder (k)b
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min required) 33>0 gpd Calculated design flow Design flow provided 350 gpd
Plan: Date Number of sheets Revision Date
Title 1 I i�-4 I M I StrEPi. :F.r L, C" -T. Letzo2. 70C*,?.. L, -d,,, 0.. <, yAvn-w,)`9 . M A
Description of Soil(s) _
Soil Evaluator Form No.
'/ 7-0 13 o u IV Lu
Name of Soil Evaluator 12-3 Wdl,4c— Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS VSV PI!}Au IScu Cjal D1^r.1lalPI!
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of to ce th system in operation until a Certificate of CompIian%e has been issued by the Board of Health.
Signed Date 6--//Olal
R
i
r�
Inspections
No. �/ � FEE :Z
COMMONWWTII Of MASSACHUSETTS
Board of Health, YID rnio , MA. }r�`
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) , Complete System
The undersigned/ hereby certi that
the SewageDisposal System; Constructed ( ) , Repaired ( ) , Upgraded,(- �Abandoned�
ge
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No.,O -Q , dated -17-01 Approved Design Flow (gpd)
Installer C��, laz�71/j
Designer: o �A Inspector: Date: 5
The issuance of this permit shall not be construed as a guarantee that tKe system will function as designed.
No. ° i�lJ%dGGT%/ FEE
COMMONWEALTH Of MASSAC14USETTS Iff
Board of Health, *1 M D 07 -H , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upg`rade (/� Abandon�n individual sewage disposal system
at 1 0 C A—L2� i4 ti• y L (_ n o �� , J `%� YYI Kms` as described in the application for
Disposal System Construction Permit No. dated
GAS.
Provided: Construction shall be completed within tb rs- f the date ofthis ermit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date !� Board of Health