HomeMy WebLinkAboutApp-Permit-Compliancey, ThrIMUU 1 H HEALTH DEPT.
-= 1146 ROUTE 28 _ FEES
N SO. YARMOUTH, MA 02664
COMMONWEALTH Of MASSACHUSETTS
Board of Health,
S FO I SAS. S r42144vid..l
MIT
Applic tion for a Permit to Construct() Repair pg de( ) A don ) - Components
Location „Z 41,6 r- (, /P
Owner's Name G t ass OA Po •V
Map/Parcel# 3 L �—
Address A; R Dd &'P -g a,P A,, -PW
Lot#
Telephone# _Cop -
Installer's Name & C d
Designer's Name
Address 15-0 4, 57- 4j_Y,04,,p
Address
Telephone# r),)S" -,A { 04
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
aI/S £
gpd Calculated design flow
Number of sheets
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria ( )
Design flow provided gpd-
Revision
pdRevision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS DYJ /A,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree tv
not to place the system in o� ration until a Certificate of Compliance has been issued by the Board of Health.
Signed VLealkA An Date 7 ^ 9-.9
(57
Inspections
No. 31� COMMONWEALTH
MMONWEA TH ®f MASSACHUSETTS FEE
Board of Health,MA.
CERTIFICATE Of COMPLIANCE
Description of Work: V Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired:, Upgraded ( ), Abandoned ( )
by: h iig CdNCo -3<3'a ✓1 ,01A-, s
at _c% A j*O B FR%A aR L✓ ' y/�/P
has been installed i cco dan with the provisions of 3 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _ dated Approved Design Flow (gpd)
Installer
Designer: v1--" Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �i?- -3LY FEE
C®MI ONW-EA T14 Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) RepairO(j Upgrade( ) Abandon( ) an individual sewage disposal system
at 06�/P-T 280 Lo g as described in the application for
Disposal System Construction Permit No. dated`
Provided: Construction shall be completed within three years of the date of this per All local conditions mustbe met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date � Board of health