HomeMy WebLinkAboutApp-Permit-ComplianceNo. oz -93
YARMOUTH HEALTH DEPT.
SO. YARMOUTH, MA
Board of Health, MA.
FEE 59'
APPLICATION FOR DISP®SAi YSTEM CO STRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade ) Abandon() - Complete System ❑ Individual Components
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LocationVE
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name r1q0 f L
Designer's Name
Address PO.460A 413/ -4 0V10 /! g
Address >� /
Telephone#'1560
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets )revision Date
Title
Description of Soil (s)
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr not to pl a em ' o ration until a Certificate of Compliance has been issued by the Board of Health.
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Signed z;9 Date �
Inspections
No.
COMMONWEALTH OF MASSA'L.14USETTS FEE
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Board of Health, G1�iY� ✓d?U2/%7� ; MA.
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CERTIFICATE OF COMPLIANCE 1-) R1 CSU M rrr!'n
Description of Work: ❑ Individual Component(s) Q160mplete System Jae.
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded ( ), Abandoned ( )
by:
at r
has been installed in accordance with the provisions Z10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 3 `i� -Z—Approved Design Flow and
Installer �� � 19771ZJ)
Designer: . 7 -Inspector:wFDate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.>
No. 0 93-(� �T��j�im� &�lZ
'`��(ml. FEE 4
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Board of Health, ✓%/1_ 1r�` , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT /k'�
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (, r Abandon ( ) an individual sewage disposal system
at /J�%� as described in the application for
Disposal System Construction Permit No. ,�� 93 , date99d,,�
Provided: Construction shall be completed within' jt eAS" f �e date of this -mit. All local conditio s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �U ��Z Board of Health