HomeMy WebLinkAboutApp-Permit-ComplianceNo. "/` S AW/ Owv Z y/`/ FEE
COMMONWEALTH OF MASSACHUSETTS
YARMOUTH r
Board of Health, • •-- :EALTH , M -
APPLICATION FOP, DISPOWM 14 T*UCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System /Individual Components
Location 3 CI —"O'X,06�41 /OF40 4ef401'� J7/
Owner's Name
Map/Parcel# 400
Address --� e�iQi� �O • G���/
Lot#
Telephone# `
Installer's Name ��,��'!`y
Designer's Name
Address ;�/ ,� ��' '�6 /�/.
Address
Telephone# ��3'0?�7
Telephone#
Type of Building`'
Dwelling - No. of Bedrooms
Other - Type of Building
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 ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS�'��`
The undersignedagre s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t lace the m in operation until a Certificate of Compliance has been issued by the Board of Health.
SignedDate
Inspections
No. D / %I fJ J`/il/il FEE %!/i l/V
COMMONWEALTH Of MASSAC14USETTS 4 %' 2
Board of Health, G 'AM. � ` �
CERTIFICATE Of COMPLIANCE le)
Description of Work: A Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: -e?wwd�el �
at-34�1 owe
has been installed in accordance with the rovisions OV10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated (o . Approved Design Flow (gpd)
Installer
Designer: Inspector: ! Date:`f%� r(^
4
The issuance of this permit shall not be construed as a guarantee at the system will function as designed. ___
No. � v ezll FEE t ci t i
�YY/
COMMONWEALTH OF ®F MASSAC14 SETTS
Board of Health, l / MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT b-/.,ol f
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at –7 �i�,�'� �� s�r/����-� as described in the application for
Disposal System Construction Permit No. 6U `J dated��
Provided: Construction shall be completed within th f"s'5of the date of this ermit. All local conditions must be met.
Board of Health
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date K 7 f% (� '