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HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH Utl' 1. -'— 33.3 1146 ROUTE 28 FEE ' SO. YARMOUTH, MA 02664 COMMONWEALTH OF MASSACHUSETTS Board of Health, , MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) - ❑ Complete System j Individual Components Location ,Z r/ Owner's Name /PRe S 11.4jnC G Map/Parcel# Address I i %%L £ ro" Lot# G% —3 Telephone# .f0 r �' f/_ ;j-r?2 Installer's Name A 1,Q CANCQ Designer's Name Address '3 S- 0 /h/31/ -v S7- /9 Address Telephone# Telephone# Type of Building At 0 0,5 Z Dwelling - No. of Bedrooms Other - Type of Building No. of persons Other Fixtures Design Flow (min. required) Plan: Date Title Description of Sdil(s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ,%►i ,64 �=/ ti £ C �i9tix i The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date g Inspections No. �1 Y- 33 FEE C C®MM®NWF—ALT14 OF MASSAC14USETTS Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: IVIndividl> omponent(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,0, Upgraded ( ), Abandoned ( ) by: fi 68 04 4.1Co 3So 1".Vi.0 57- tv S-wIc at S� 3 «4 /7`L £ 411- S SWf has been installed in ac ante with the_provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. w `�� dated ' �dl�lc�i Approved Design Flow (gpd) Installer Designer: 1.11 Inspector: --1 Date: em .fas designed. _ The issuance of this permit shall not be construed as a guarantee that thesystemon No. COMMONWEALTH Of x'1['1[ SSAC14US ETTS 10 FEE Board of Health, Yom'✓ `^'�"� MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(.Y) Upgrade( ) Abandon( ) an individual sewage disposal system at —V3 1 �7`L E / ®P F,P "/, S a Y/�, /,p as described in the application for Disposal System Construction Permit No.33 dated Provided: Construction shall be completed within three years of the date o is per i All local conditionsmust be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dated 1,L � Board of Heal