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HomeMy WebLinkAboutApp-Permit-Compliance'�-,i,q YARMOUTH HEALTH DEPT. riJ�J; 4 FEE 1146 ROUTE 28 COMMONWMTARM?RAkVFff tSETTS y Board of Health, , MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct epair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location©� %L( .9+✓J� r% s X Owner's Name C dly E �/ Map/Parcel# �� /� t}-- Address 3 Slldlj&A � ,�� V/ J. Lot# s/� �'� _ Telephone# -3eu-- J -V P r— Installer's Name- Designer's Name Address Address Telephone# Telephone# -51,1 -5c, -722'Z— Type of Building �� �r��r' C Lot Size 7 3 0 9 7 sq. ft. Dwelling - No. of Bedrooms J Garbage grinder ('lfvo Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) p ('Gf' gpd Calculated design flow 336 Design flow provided -3r/- ygpd Plan: Date Number of sheets Revision Date Title / R�Pe f s�j ,-4---77 C- l Csi►/L� �c�'2 �trlr�-t a -u ' �✓ S7a s-'�! �ul �Oy� S Description of Sdil(s) (5 &--a- l" � -/- ) _ n l<Cme, Soil Evaluator Form No. Name of Soil Evaluator T. /7✓ r+ -r✓ Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 7 Thejas agree to ' e ove des d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furto not pl a on until a Certificate of om 'ance has been issued by the Board of Health. SignI A J77MAX A.,01 Date ''Inspections No. W -FEE X0 / COMMONWEALTH Off' MASSA : US ETT � . f- .�Lty� Tn nil. Board o Health, G CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 1L.Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed fO(t)Repaired O U raged.( ), Abandoned ("' by. at has been installed-"' acco dance with the�rovisions o 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to application No. - dated6 ' Approved Design Flow _'�Pd) Installer / / / Of Designer: Inspector: Date: The issuance of this permit shall not be construed as a guar tee that a system will function as desi No.- COMMONWEALTH OF MASSACHUSETTS Board of Health, z ✓%? �� , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE�J G Permission is hereby granted to; Construct( --<Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at 50/ l``/Gi/nl�C as described in the application for Disposal System Construction Permit No., dated e Provided: Construction shall be completed within three years of the date of this perxpi.�l All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date oard of Health