HomeMy WebLinkAboutApp-Permit-ComplianceYAFiMUU 1 H HtALI H Utr 1. y /r
N°49V 1146 ROUTE 28 l � 00
., � ����� SO. YARMOUTH, MA 02664 � ��� ��S q� FEE '
Board of Health, 7 A Rwt o o j- �MA.
4'W'APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
"y
Ap ication for erml to C nstct(!/j e i gra ) andon() - 'Complete System ❑ Individual Components
Location L.�kA
16KELV6
Owner's Name /
ap/Parcel# :2,z
n.= L .23 O
Address 3& LEwedrLJ
ot# 3
Telephone# 5-OF 9PLP -OW11
-
nstaller's Name
Designer's Name
t
ddress rl b
W t z
Address
elephone# -5--
Telephone# So 36 -
Type of Building 1 e 56 d a-zce Lot Size Z sq. ft.
Dwelling - No. of Bedrooms e o Garbage grinder K�D
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) // gpd Calculated design flow 33 b Design flow provided 35a gpd
Plan: Date /D? -1/11- ao/rn Number of sheets Revision Date
a Title
Description of Soil(s) 0 Ils- A F 6 -8 4' -26= /-70 % C f/ p' 4L/s- /�- �E ' //3'°2 d! —Aen
Soil Evaluator Form No. Name of Soil Evaluator 1W, j G �u1slCu�T Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS /� 57( (i1 ,q u ,Jr7,11� �z5e fTik a , C-'o,,rjsf s/; ;ice C5
i/10i-4 %W.-rr.. w , i\ cr_/J I.. it/. :V ^ �a tP-/JL/�- ._,.14
The un04
dersigned undersigned agrees to install the above. described,,Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
No. a7Qvi 9 (`vg'( 9 E
Board of Health, 4 -,A-6 i t
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) W/Complete System CU 6-, 6' v �
The undersigned hereby. certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ); Abandoned ( )
by:
has been installed inf�ccorda e with the rovisions o`f- -1DCMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. X ` , dated 12- -/ Approved Design Flow -3 �U (gpd)
Installer WI) C, 155 I i
Designer: l a Inspector: Date: -.
The issuance of this permit siall not be construed as a gu tee that the system will function as designed.
No. O T ( -� �- (�� CK- FEE )Q ' 00
Board of Health, Y /1 R ,,u,, 0-r t4' , AL4.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; ConstructO Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at Z < as described in the application for
Disposal Systet])Construction Permit
Provided: Construction shall be completed within miLae4wafs of the date of this permit. All local con- . ions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA (� Date ( �� Board ofHeaJth
1jA l/ /I, f 4 ii^ , ✓ {. k l�G/,-