HomeMy WebLinkAboutApp-Permit-ComplianceNo.
® FEE ��
Board of Health, YARMOUTH HEALTH RWT.
1146 ROUTE 25
APPLICATION FOP, DJSPOSA0-MPWC,0N9?WKCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location % /gpy/ZG2 G ii.
Owner's Name G� GGG
Map/Parcel#
Address 3'9
Lot#
Telephone# `
Installer's Name
Designer's Name 17 _<1We��
Address
Address ��i4T Gtrls7�it�+— /sem
Telephone# ,S -2::i 02 J�G' X-3 ,re
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 33 O gpd Calculated design flow
6
Plan: Date / 1 - Number of sheets
Title
Description of Sbi1(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
3 �Z
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS ,Z'''Sip /� �J"Ga �✓G S'�/✓ %/C �' �� ��(
/�i'l•> e /�li/��s �✓J j�//®y ./� �C> ��iL%w�GGf �v�� .S7a/I/ P
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to no to place the system in operation until a Certificate of CComplianrc�e has been issued by the Board of Health.
Signe Date
Inspections
No. � 'L_.®1`�lll`�ll®1V` V'V' E1"�Yll,T� OF 1`�ILASSAC��lJSETTS FEE �G! CG'
Board of Health, �/✓/liJO�i�j°j' MA. "' �` �`^ E/
I CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 1A Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (/), Upgraded�V), Abandoned ( )
by: ✓ /�l!i �%
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. �`%T , dated _ . Approver�esign Flow -: -(gpd)
Installer -./1
--A -C
�
Designer: C, ms's %'� Inspector: v Date:
The issuance of this permit shall not be construed as a guarantee that the yst/m will function as designed.
No.V✓ FEE _
Board of Health, G �i MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
S'O. GG
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (�) Abandon( ) an individual sewage disposal system
at c -,e G A-'
Disposal System Construction Permit No., dated
r //�`�
Provided: Construction shall be completed within thxe��ePNr
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / Board
as described in the application for
rD
of the date of this it. All local c
y
o itions must be met.
,✓ie r
of Health `,. ,111