HomeMy WebLinkAboutApp-Permit-Compliancex/1.3 YARMOUTH HEALTH DEPT.
No. 1146 ROUTE 28 FEE N �
M �T��rSO. YARMOUTH, MA 02664
COMEALTH OF MASSACHUSETTS
Board of Health, l , MA.
APPLICATION FOR DISP®SAI S ]1 STEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair& Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location '
Owner's Name
Map/Parcel# ,
Address c2fU A
Lot# X 3
Telephone#
Installer's Name 1�
Designer's Name
Address 3 3b 34` L
Address
Telephone# _CIL
Telephone#
Type of Building
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
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS nin In e Kr feMer4
The undersigned a t stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of csystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Dates_
Inspections
No—, 1 13
COMMONWEALTH EALTH ®f MASSAl 14USETTS FEE
Board of Health, (. /9 j4 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereb certify that the Sewage Disposal System; Constructed ( ), Repaired O., Upgraded ( ), Abandoned ( )
by: A u
at _�? q (MAflu��2__
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. c%` �'/�� 3 , dated l O jr Fi' Approved Design Flow (gpd)
Installer A J- 4 C _A, "1 17
Decigu Inspector:
The issuance of this permit shall not be construed as a gu antee that th
No. -x/13
Date:
system will function as designed:
FEE /V• C
COMMONWEALTH Of MASSAC14USETTS
Board of Health, C , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (K Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. 12) - Y 13 , dated 10 !;2y
as described in the application for
Provided: Construction shall be completed
lwi'4-L�l/�I rs of the datAois perm' .All local condi ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / 7 Board of Heal