HomeMy WebLinkAboutApp-Permit-ComplianceNo. ' �j ! � ` ®`r // �N/ 4'G j 4f1v FEE u�
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COMMONWEALTH LTH ®f MASSACHUSETTS
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YARMOUTH HEALTH DEPT.
Board of Health, 1146 RO ;9 28 , MA•
APPLICATION FOR DISP®SN'0MTMtMVCTI®N PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System yIndividual Components
Location L14(
RQv�-
A 7
Owner's NamelA� [lel
Map/Parcel#
a I;-�
Address ` [ 1°��L c)E.�7�i
Lot#
Telephone# ,
Installer's Name
G�62fs
Designer's Name
Address l�;�;l
5 ���
Address
Telephone#
50 2 -- olZ -7:9,7
Telephone#
Type of Building P-M(bail 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)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree to no lace the system in operation until a Certificate of
Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. I<,) o,.i mac - 1-7-003-7 COMMONWEALTH Of MASSACHUSETTS Ae �-FE> �
vc C C;4C 050 �l
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Board of Health'......V , MA.
CERTIFICATE Of COMP
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Ao", Upgraded ( ), Abandoned ( )
by: `1!AD9-,(.&Q6 EPTE"dr/
at 441 labvrg �.A "YAP-W'-a96P-T'
has been installed in accordwce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated . Approved Design Flow (gpd)
Installer L.h 4E
Designer: &?//4 Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. f;QkZ)C-1^7- 003- CGS P c ,0 lDE:, FEE C
7C COMMONWEALTROF MASSACHUSETTS
Board of Health, -y"044-4- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) ...R,e�pair( X Upgrade( ) Abandon( ) an individual sewage disposal system,
at 4141 RVUm 6PA YANmuV I k—Pug--�r as described in the application for
Disposal System Construction Permit No. 17�� , dated l
Provided: Construction shall be completed withinof thedate of this pyfmi . All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date -� Board of Health