HomeMy WebLinkAboutApp-Permit-Compliance1ZV-1 '72) COMMONWEALTH OF MASSACHUSETTS
C- /As
YARMOUTH HEALTH DEPT.
FEE
Board of Healt4l 44 ROUTE 0 MA.
APPLICATION FOP, DISAA �WWtRMRUCTI®N PERMIT
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Application for a Permit to Construct( ) Repair(p)-Upgrade () Abandon( - Complete System ❑ Individual Components
Location 16
!E
Owner's Name
Map/Parcel#z6w3
3
Address
Lot#
Telephone#
Installer's Name '
Designer's Name
d, AA2—
Address
1
Address
Telephone#
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) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) moi►— � yoa�
Soil Evaluator Form No. ✓ Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described:Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree not to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 41
r Inspections
No. r
04-42-_ `? F E
COMMONWEALTH OF MASSACHUSETT) n�
Board of Health,--
ealth,Ur MA
CEPITI 'IC ®U COMPLIANCE
Description of Work: ❑ Individual_ Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (t-', Upgraded ( ), Abandoned ( )
by: -!_.
at
has been installed in aaccordance h the provisions of 3 0 CMR 15.00 itle 5) and thea proved design plans/as-built plans relating to
application No. [il -'4,>--7 dated / :_ - Approved Design Flow �� (gpd)
Installer 1
Designer: Inspector: Date:
t
issuanceThe of this permit shall not construed as a guarantee tha the system will function as designed.
_
No. !�� % �"/ �i V� ' ���� FEE �✓�%
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �✓"����7�� , MA.
DISPOSAL SYSTVKONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( LJ� Upgrade ( ) Abandon ( ) an individual sewage disposal system
at fj, t as described in the application for
Disposal System Constru tion Permit No. 6Y-1-2 '` 2 , dated 161 ✓�
Provided: Construction shall be completed within tis of the date of this ppit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA c Date 104 -1-2— U 4oard of HealthXX-1-e-4 �-% .