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HomeMy WebLinkAboutApp-Permit-ComplianceNo.e) *DC — r? --0 Z0 COMMONWEALTH OF MASSACHUSETTS YARMOUTH HEALTH DEPT. Board of Health, 1 1 46 RO ITE26 , AM. APPLICATION F®I, DISPORLYMWM9ftCTION FEE .*70(0 `1 I PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - O Complete System *Individual Components Location Ha 1 L4-AaAb Owner's Name (C.4-rtj6p 6 Map/Parcel# Address23 _ ,JIB Lot# Telephone# Installer's Name t Designer's Name (V`� Address t 5 Telephone# 7 -2271 Address Telephone# Type of Building 'R1✓5l Lim 1 1 A -C. datV'op Lot Size Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. required) Plan: Date Title Description of goil(s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator sq. ft. Garbage grinder( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS lJs- S>V /`f d4l�t/ TLS ©ill f Ill L� l gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees toplace the system in operation until a Certificate of Compliance has been issued by the Board of Health. ,pfflSigned Date 10— Inspections No._�G (7 -ND) COMMONWEALTH OFMASSACHUSETTS FEE ��-�_ Board of Health, `" y CERTIFICATE Of COMPLIANCE Description of Work:Individual Component(s) ❑ Complete System The undersigned here4certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded( ), Abandoned ( ) by: at 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 Approved Design Flow (gpd) Installer G Designer: Inspector: Date: The issuance of this permit shall not be cons ed as a guaran ee that e stem will function as designed. / No. O n , 1 i1i t -7-042Z C -A P0,i /e- FEE //q / COMMONWEALT14 Of MASSACHUSETTS Board of Health, t , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(X ) Upgrade( ) Abandon( ) an individual sewage disposal system at — LL �` 1 + tt V l j7 n ,. J7o as described in the application for Disposal System Co0- Permit No. (H�aged ) 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. Chades own, MA Date / e Board of Health