HomeMy WebLinkAboutApp-Permit-CompliancecommoNwEALTH ®r MASSACHUSETTS
Board of Health, YARMOUTH HEALTH RAPT.
1146 HOU 1 F= Z
r
TH DEPT.
Application for a Permit to Construct( ) Repairm Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location 5(Q 0.A(7'Z' 6FAOLEY Pt QW0
Owner's Name C DA LJ gZ
Map/Parcel#
f 5 5
Address < p -C
Lot#
Telephone#
Installer's Name CAP
ag _
Designer's Name �l
Address 153
Address
Telephone# 60 2 _
7— F5�'-7
Telephone#
Type of Building R E� 11)6x)-r,(A-L_ Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS "1 � �'�('� A-�43k�) k4"10 0--60K
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 lace th system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed G=Date
Inspections
No. q-7 X k661 / �A Lf /rFEE -
I
COMMONWEALTH Of MASSACHUSETTS
Board of Health Vd MA.
CERTIFICATE Of COMPLIANCE
Description of Work:Individual Component(s)
The undersigned hereby certify that the Sewage DI
by:gLl - F c tj�i� � n
at �/ ryA J—. AftknAl A l�
❑ Complete System
sa System; Constructed ( ), Repaired ( /pgXh(dc� d0 n`(f
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. dated Tp ,T/ 7 . Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gua,,97 a that the system will function as designed.
No. 1, -i\tjy
FEE J
/7- - ` 7(, COMMON LTII ® MASSACHUSETTS 446 8
Board of Health, VA ,, If ., r jzn4
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade L_)- Abandon( ) an individual sewage disposal system
at 1 as described in the application for
Disposal System Construction Permit No. r 7, dated //- T
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. Chadestown, MA Date/ 4`',' 7 Board of Health