HomeMy WebLinkAboutApp-Permit-Compliance14t — d d
No. ca t r FEE -5,1, r
/X6�L5�COMMONWEALTH Of MASSACHUSETTS pe C�k*G
Board of Health, YARMOUTH HEALTWDEPT.
APPLICATION FOR DISPOSAt=L&)6TWi6TION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
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Location 3
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Owner's Name ,V
Map/Parcel#
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Address v
Lot#
Telephone#
Installer's Name
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Designer's Name 6 N
Address
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Address t=W rr C
Telephone#
Telephone# _
Type of Building s r` yr.) 1 C Lot Size sq. ft.
Dwelling - No. of Bedrooms Garb1g4'T int t
e r�er ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. re uir ) S gpd Calculated design flow Design flow provided gpd
Plan: Date eo Number of sheets j Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
nhe undersigned agrees stall the above escribed Individual Sewage Dispos yst in accordance with the provisions of TITLE 5 and
,further ees t no o e th to operation pastil a Certificate of Co `lian has been issued by the Board of Health.
Signe G-vc��0 Date P zu
Inspections 10-2—,VV
No. Ce -� V (� FEE 5� r
`COMMONV'�'��7 EALT14 OF MASS . IIT SETTS
Board of Health, MA.
CERTIFIC COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System w
The undersi ned h by certify that he Sew ge Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: C 1.0461
C
at
has been installed in airc r/ance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application -N -0-D-011-1) ` 6 dated t ` ` 1 { -OG . Approved Flow f11(gpd)
Inspector: T%�7 l#Designer Date: 10 / 00�
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The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. QG� `- , G FE rO ®�•
C®MMONWFALT14 Of MAS AC14USETTS cp� o � d
Board of Health, �T T MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is/her by granted to; Construct( ) Repair (1/) Upgrade( ) Abandon( ) an individual sewage disposal system
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as described in the application for
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Disposal System Constr ction Permit No. dated _J�f/j 0 (i .
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Provided: Construction shall be completed wit in �rs�of the date o is per it. All local c ditions must be met.
Date Board of Health
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA �� C/�