HomeMy WebLinkAboutApp-Permit-ComplianceNo. O10 t q /4 FEE
COMMONWEALTH Of MASSACHUSETTS . oy
*x Board of Health, YARMOUTH HEALTH D
1146 ROUT%2& °✓ elkAPPLICATION FOP, DISPO�iAWW "RRUCTION PERMIT
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Application for a Permit to Construct( ) Repair( ) Upgrade(V�'Abandon() - ❑ Complete System &Individual Components
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Installer's Name tp
Address/
AddressTele?� . / ��.�. �/ • AGI
. 410r ---% ■ v
- 0.4 WEN
Type of Building NE
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures U4441i
Design Flow (min.
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Plan: Date q I
Title T VCU VU Ot, V
Description of Sdil(s) _
Soil Evaluator Form No.
No. of persons
Lot Size i t sq. ft.
Garbage grinder
Showers (Cafeteria
gpd Calculated design flow 7 _ Design flow provided gpd
9 Number of sheets 2. Revision Date N A
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
i
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date -7 -
Inspections
No. -06-177
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
CERTIFICAA OF COMPLIANCE
FEE %U t
C
-
/I/"DescriPtion of Work: QIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (-J, Abandoned ( )
by:
at
has been installed in acc
application No. C.6
Installer
Designer:
The issuance of this perp
No. 06 -
bo �
with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
dated` ( Approved De 'gn Flow(gpd)
dim
Inspector:
Date: X
shall not be construed as a guarantee that1he system will function as designed.
FEE
COMMdNWEALTH Of MASSACHUSETTS
Board of Health, , MA.
DISPOSAL SYSTEM 6NSTRUCTION PERMIT /
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. 610 /7 , dated d `:2
Provided: Construction shall be completed within tbbr6 vof the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 0611oard of Health