HomeMy WebLinkAboutApp-Permit-Compliance�y 0 YAR- MOUTH HEALTH DEPT.
No. 9� - , 1146 ROUTE 28 FEE �
SO. YARMOUTH, AAA 02664
Board of Health, �.
APPLICATION FOP, DISPOSAI SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UT ade( ) Abandon( - [r'Complete System ❑ Individual Components
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Location
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Owner's Name
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Map/Parcel#
3Address
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Lot#
-15 ""
Telephone#
Installer's Name
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Designer's Name
Address)
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Address
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Telephone#
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Telephone#
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Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 74Garbage grinder (/V
Other - Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures nn ^ ��'�'
Design Flow (min. required) Q gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets / Revision Date
Title 4
Description of Sdil(s) _
Soil Evaluator Form No.
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DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Y )-. /7/hi4-9:-- Date of Evaluation , —7—P
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no 1# the sys m in er 'o til a Certificate of pliance has bee issued by the Board of Health.
Signed Date
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1
Inspections
No. `��f � �d � FEE
COMMONWEALTH Of MASSACHUSETTS �
Board of Health,/✓ MA.
CERTIFICATCOF COMPLIANCE
Description of Work: ❑ Individual. Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Dispoyl System; Constructed ( ), Repaired ( ), Upgraded (Y Abandoned ( )
has been installed in accordance with therovisionsGo�f 310 CMR 15.00 (Ti tj� 5) and the approved design plans/as-built plans relating to
application No. �� dated ` Tom` FP . Approved Design Flow (gpd)
Installer —LLQ J /��(/ Ff G7'L.,.�
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Designer: r /� C31�� Inspector: ate: 1->-3- /
The issuance of this permit shall not be construed as a gu antee that a system will function as designed.
No. r0 FEE J
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 12 MA.
_ a 60° S DISPOSAL. SYSTEM 'NSTRUCTION PERMIT
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Permission is hereby granted to; Construct( ), Repair ) Upgrade (/)Abandon( ) an individual sewage disposal system
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Disposal System Construction Permit No. 787- '� , dated
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as described in the application for
Provided: Construction shall be completed within three years of the date of this p it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dae Board of Health t! .
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