HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. �—� 1146 ROLWE 28
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSAC14USETTS3
Board of Health, MA.
FEE o,
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"""" ' I APPLICATION FOP, DISP05tiL SYSTEMCONSTRUCTION PERMIT
Application for a Permit to Constructo Repair( ) Upgrade( ) Abandon( ) - &Complete System ❑ Individual Components
Location76
VE7 -ST— yak rn 0 u ?ort VyJQ
I Owner's Name p 2T (A) ,
Map/Parcel#
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Address tRloO� �^ Q
Lot# ATelephone#
Installer's Name
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Designer's Name M d 0 9 1 n Q60-4At 1A
Address
Address
q4-1 vl S . So , IC
Telephone#
Telephone# 35
0% _ 1`32_—
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Type of Building7P,&_,0 ,.L A Q V1.GLz� Lot Size 44e4 ('OO sq. ft.
Dwelling - No. of Bedrooms Garbage grinder *0
Other - Type of Building .No. of persons Showers( ), Cafeteria ( ).
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date iT 9 8' Number of sheets Revision Date -11 4.4i
Title
Description of Sdil(s)
Soil Evaluator Form No.. Name of Soil Evaluator eCA) (Qd! 1I40G Date of Evaluation ::57
Fr—
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above descried Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr es not to place e s tem in opera n until a Certificate of Compliance has been issued by the Board of Health.
Signed'M:�- ( Date (� 3—
r�
Inspections
No. FEE leg
COMMONWFA T14 OF MASSAC14USETTS
Board of Health, ✓1w'Onn' f MA.
CERTIFICATE Of COMPLIANCE
Description of Work: El individual `Component(s)Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded ( ), Abandoned ( )
by:at 76
has been installed in accor'ta ce with the
--
provisio'ns of 310 CMR 15h00 (Title 5)' and the approbed' design f laps/as-built plans retating tb
application No. 9d'' 477 , dated ��" ` �� Approved Design Flow4(gpd)
Installer
Designer: Inspector:
Date: 1 -27 -
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.>-
COMMONWEALTH OF MASSACHUSETTS
Board of Health, t/✓�32'� /T . MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct I Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 7% r/eb/t/e,� p as described in the application for
Disposal System Construction Permit No. 7S`74 dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions mu t be met.
Board of Health
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date,//