HomeMy WebLinkAboutApp-Permit-ComplianceNo. _ ti FEE %DC/. /. QO
ArzWYL- COMMONWEALTH OF MASSACIIUSI
D4TS
n Y
Board of Health, YARMOUTH HEALTH DEE
1146 RvUT E 28
APPLICATION FOR DISPOS�%"PRMNTMCTION PERMIT
Application for a Permit to Construct( ) Repairp�Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 1- &
Owner's Name
Map/Parcel# - /oi o`�
Address
Lot#
Telephone#
Installer's Name , 'b7, �%
� C l��U`
Designer's Name. f'� O,- 7'
Address
Address (J 04' AAW S• %%n ��
Telephone# y �r%
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) jyt gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(,) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTTIpON OF REPAIRS ORALTERA .IONS 4:5176 AYA' 171&1 -rl,& 6- CS, 145
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 o eratio til a Certificate of Compliance has been issued by the Board of Health.
' Signed Date`��,
Inspections
No: FEE
l
Description of Work:
The undersigned her
by.
has been installed is
application No. b
Installer
l^ WTVIMUIN V'V' EALI t Ul- 1V1AZ)Z)AH U NE W)
` Board of Health, sr n1dGG),"- h NIA, f/ U
C ERTIFICTSE OF COMPLIANCE PA�
❑ I:n ftidu`il'Component(s) ❑ Complete System
by certify that the Sewage Disposal System; Constructed ( ), Repaired (4, Upgraded ( ), Abandoned ( )
with the rovi,s}ons Q010 CMR 15.00 (Title 5) and the„approved design plans/as-built plans relating to
dated%T Approved Design Flow (gpd)
Designer: --;1/7Qr -/ Inspector: � W, /X-.~ Date: u Q* IV V -,Or
The issuance of this permit shall not be construed as a guarantee t at the system will function as designed.
No. r t �-Q t�� t°�.� `” FEE S22 !�J -
'L.®MMO WjC1 L114 OF MASSAC141JSETTS 6z06 ;:..
Board of Health, d/ , 1►ILq.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair V<
Upgrade Abandon Abandon an individual sewage disposalosal s/tem
at 4) V 1-7 %, 1(,//4? wd w -J-4
as described in the application for
Disposal System Construction Permit No. 0 S, dated F —14--0 -r
Provided: Construction shall be completed within-t#r��rs of the date of.thispermit•. All local conditions mu t be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date— 3 Board of Health