HomeMy WebLinkAboutApp-Permit-ComplianceNo. -J�� FEE �+
YARMOVTH HEALTH DEPT.
Board of Heal}l , MA. %j'�
APPLICATION FOR DIS*MrA ��1��J���®l� PERMIT
1,Abpplication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location C,
Owner's Name G
It
Map/Parcel# 7
Address S{
Lot#
Telephone#
`
Installer's Name t, S
C-�2} Designer's Name
Address
VA Address
#V
#V&
Telephone# S
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 2- S% Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided U, gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned a e to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to lac/ee t eration until a Certificate of Compliance has been issued by the Board of Health.
" Signed V �- w Date S_ �;7`— 0 6
t-
Inspectons
No. ®,r- C®1`lll`ll®1V`WEALTH OF MASSACHUSETTS �J'4_
Board of Health, , 'r . MA.
Description of Work: .Individual Confoonent(s) ❑ Complete Systex "
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned
? r •'
r`" 7
at r i �? �i 1 d 0 : it-oc', f -V k.✓ -,A,\
FEE q79 , JD
has been installed
application No. 6
Installer 1
with the provisions of 3 0 CM1�15.00 (Title 5) and thea roved design plans/as-built plans relating to
dated �1— 2-2 _iP (0 Approved Design Flow'��- (gpd)
Designer:_z,_. Inspector:
The issuance of this permit shall not be*construed as a guarantee qtht
No. —0,9
Date:
the system will function as designed.
COMMONWEALTH- Of MASSAC14USETTS
Board of Health, : 7, C P' Q an �t' MA. l O
4Y
FEE
VINFUZ)AL M'MEIVI WIN61HUL11VIN�hKY1'111
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system '
at as described in the application for
Disposal System Construction Permit No. ('� (� `�� , ,dated Y/ .
Provided: Construction shall be completed within thTee-ymmof the date of�rf its per%n fit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. &Oin Co Bon k " Date Board of Health
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