HomeMy WebLinkAboutApp-Permit-ComplianceFEE
Board of Health, 1146 ROUTE 2$ mq.
YARMOUTH MA
APPLICATION FOP,����® �L SYSTEM CONS RNION PERMIT
lication for a Permit to Construct( ) Repair=) Abandon() - U Complete System U Individual Components
Location 3 (a — 3 1
t 15W . re
Owner's Name (',v. I
Map/Parcel# Y �(
— 07 �%
Address
Lot#
Telephone#
Installer's Name
A & B CANCO
Designer's Name r v
Address
350 Main Street
Address
Telephone# W.
MA 02673
Telephone# 3 L�
of Building Ic,c S Lot Size sq. ft.
ing - No. of Bedrooms Garbage grinder ( )
-Type of Building No. of persons Showers ( ), Cafeteria ( )
Fixtures
i Flow (min. required) gpd Calculated design flow
Date �G�-a 1 Number of sheets
C_ ..
;ription of Soil(s) _
Evaluator Form No.
Name of Soil Evaluator
OF REPAIRS OR ALTERATIONS �2 E_ � I /4 lj
Design flow provided -t J gpd
Revision Date
Date of Evaluation
undersigned agrees to ins%the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
her agrees to not ace tem in operation until a Certificate of Compliance has been issued by the Board of Health.
ed T9 Date /a 113 -,� b
FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health,a' , //`/ , MA. //G Z( -10-K
CERTIFICATE Of COMPLIANCE
iption of Work: U Individual Component(s) Ja Complete System
indersigned hereby certify that the Sewage Disposal System; Constructed( ),Repaired ( pgraded ( ), Abandoned ( )
een installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
cation No. 02 `(✓ (D , dated 1- % Approved Design Flow (gpd)
/�� / e� � ,f 7/ 7`� /4/�: Inspector: � -z"tia Date:
ice of this permit shall not be construed as a guarantee that the system will function as designed.
� �XA.1 o FEE
C®MMONWLALT14 OF MASSAC14USETTS
Board of Health,!1 t % %G % MA.
DISPOSAL SYS CONSTRUCTION PERMIT
Permission is he eby granted to; Construct( ) Repair( rade ( ) Abandon( ) an individual sewage disposal system
at /� Y,«%/ �� �, .�5� aJ C� / CZ /� as described in the application for
Disposal Syst(m Construction Permit No. GZ 4�4 , dated 7 92
V"✓L07
Construction shall be completed witl}i-ter ars of the date of this per it. 011�41
al conditions must be met:
o v 596 M sulkin Co Boston, Ma Date 7-102—Board of Health/,