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HomeMy WebLinkAboutApp-Permit-ComplianceNo.2?*DC—r?-4n COMMONWEALTH OF MASSAC14USETTS YARMOUTH HEALTH DEPT. UJ Board of Health, 1146 R01 -ITE 26 , AM. 17 APPLICATION FOR DISP®RLy d CTION � Application for a Permit to Construct( I 92r FEE ��(0 & PERMIT Repair X Upgrade( ) Abandon( ) - ElComplete System *Individual Components ocation L..&C— AcAb Owner's Name CA -r (6;W 6 gAK ap/Parcel# Address Lot# Telephone# ` Installer's Name t Designer's Name (V`� Address t; kofW Address Telephone# 5&R 7-221-1 Telephone# Type of Building RES i L�S)-� l 16-e__ damp Lot Size Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(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 gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS :2OS-NC1_ -:jiW 1:r, -T45LS:' ©A J' JAI 4LE- (` The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date /0—J-7-17 Inspections No. 1-7 C®MMON�I.T14 Of MASSACHUSETTS FEE ^ Board of Health, V � ' MA. /V/� &-�-0 � CERTIFICATE Of COMPLIANCE Description of Work:Individual Component(s) ❑ Complete System here The undersigned 4certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( ) 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 constr ed as a guaran ee that a sy tem will function as designed. No. r2 j 6TH, p6 CA poo /De- COMMONWEALTH lieCOMMON LTH Of MASSACHUSETTS Board of Health, e „ M ._ _ t , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(X ) Upgrade( ) Abandon( ) an individual sewage disposal system at _L14k (tele tLT,GA 00(b as described in the application for Disposal System Construction Permit No. A , Cg_ 1 %-(H�fflaed 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. Charlestown, MA Date / / Board of Health 4 / i