HomeMy WebLinkAboutApp-Permit-ComplianceNo. T � `- .� / ' �' FEE 'T
COMMONWEALTH Of MASSAC14USETTS
YARMOUTH HEALTH DEP
Board of Health.
APPLICATION FOR DISP8 GYM WN 1RUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location SY- s arr O L./
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Owner's Name ; Aord SrOnojp
Map/Parcel# 9p pk 16 7 pQ
e X03
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Address S'C� S arr0 w In/d S; �Ot/YI o�J
Lot# 0? /> -7'715,3
9 r.Zj
Telephone# $Og 94 G o0 3
In Name 0 0 b� �pr
�n
Designer's Name O pVi d C '� U
A;JoressPCOt lr�
or f�50
6S31
Address /1IViIi� < f -0e) WiC4 Qoas3-7
Telephone#g
Telephone# 5`p�
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required//)
Plan: Date �� /� � /`19
S -0n9 �� �pmi 4/ i°re$ l'01l'4 f Z Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
13-�3ry
gpd Calculated LLdesign flow ??0 Design flow provided gpd
/�
Number of sheets ` - _- Revision Date
Title
Description of Soils) �5-Ce
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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
"Inspections
No. as - —S^l COMMONWEALTH Of MASSACHUSETTS FEE 5. A02
Board of Health,
CERTIFICATE &COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Aban& & ( )
by: :Z244 A4�-q4n f ,"
has been installed in ac or nce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ',dated / J''f �. Approved Design Flow (gpd)
Installer % U/ i /�-14-Z-77A/ -
Designer: / /77 y Z-/zL-1 Inspector: : LkA ` Date: "" ` CC)
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ii V 111MW7/\/ FEE
COMMONWEALTH OF MASSACHUSETTS /I r�r4�
Board of Health, ✓!'t , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct (�) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at �U (,�,.�/ ��ti:-Q as described in the application for
Disposal System Construction Permit No. 6V ` dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /� Board of Health C/ ,
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