HomeMy WebLinkAboutApp-Permit-ComplianceNo.., �! c/ .<r� .. FEE _® /
COMMONWEALTH OF MASSAC14USETTS
YARMOUTH HEALTH DEPT
Board of Health,, MA.
146 ROUTE 28
APPLICATION FOP, DISPM4IA� 044N SUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - alfl�omplete System ❑ Individual Components
Locationjj 1 ��. ( �( S A I
Owner's Name a cS ' ( _
Map/Parcel# 8c
Address
Lot# scl ,
Telephone#
Installer's Name � � ��p � r^ LL
Designer's Name �p�,
/
Address %� GJfi7�F���k� Y �� `l�
Address a3� I%"
Telephone# 0(5'- 3,—,r -:S
Telephone# 9K
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date I)-- _GJ Number of sheets
Title
Description of Sdil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date 6 — 1 " O 0
Date of Evaluation
The undersigned agrees to install th5 abov escribed Individual Sewage Disposal Sy tem in accordance with the provisions of TITLE 5 and
further agree t ac e.. t in operation until a Certificate of Cf,!p' ce has been issued by the Board of Health.
Signed _ Date Orel
0
Inspections
No. ea --318
�. Board of Health, MA.
CERTIFICATE Of COMPLIANCE
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FEE
g/7fov
Description of Work: ❑ Individual Component(s) ZW5mplete Syste10
m^'fir
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (� , pgraded ()Abandoned
by: su. '� S LW re— L t4 V-
at )L D6R
has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No .CO3) �I dated (10. Approved Design Flow A �t (gpd)
Installer So v�\ "Id f LA
Designer: '� C -t.' --et J-S`p ft_ Inspector: Aocw Date: 7 1710
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. (YJ` t V FEE KC)
C'®MMONWEALT14 Of MASSAC141u, SETTS dk r4 Aoq i
Board of Health, ✓ ►�^ �' MA.
DISPOSAL SYST 'JC' CONSTRUC11ON PERMIT
Permission is hereby granted to; Construct( ) Repair (L-' t pgrade( ) Abandon( ) an individual sewage disposal system
at o2 �- s� G.L..t S '
as described in the`"application for
Disposal System Construction Permit No..Ck)-S, 16 dated a
CAAVK
Provided: Construction shall be completed within-,4�rs of the date of this per 1 Al local co s must be met.
Form 1255 Rev. 5/96 A.M. Su'l'kklin Co. Boston, MA Date IL Board of Health;