HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. D 'J� 1146 ROUTE.23
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSACHUSETTS
F CJS' l Z-5 Board of Health, , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade>() Abandon( ) - f complete System ❑ Individual Components
Location
Owner's NameaRam
Map/Parcel#
Address a
Lot#
Telephone#
` IV
Installer's Name �(� �J /)
C Designer's Name
�W/-
Address �x : /
Address
�O
Telephone#
Telephone#
Type of Building KV—
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min re uirdd) � gpd Calculated desi flow Design flow provided 1W gpd
Plan: Date ��2-10 / Number of sheets _ Revision Date
Title
Description of Sbil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil
Date of Evaluation
.,,The under ' ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further t ac the syste operation until a Certificate as been issued by the Board of Health.
Signed Date ��
's
Inspections
Board of Health, YA9 12 /7�1 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Component(s) 9 Complete System
The unde> kigned hereby certify that the Sewage Disposal System_ Constructed ( ), Repaired (, ), Upgraded (t), Abandoned ( )
by: v I..� v
at
has been installed in accordance with the provision f 311 CMR 15.00 (Title 5) and he roved design plans/as-built plans relating to
application o. - / , dated Gam' _ �/. Approved Design Flow(gpd)
Installer f C -
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee Wat the system will function as designed.
Board of Health MA. r
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade X Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit Now dated/2
6> VP495
Provided: Construction shall be completed within tkwec=F=rs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date�%�oard of Health
gIi G/ r) X,11< -PZ, : �� /