HomeMy WebLinkAboutApp-Permit-Compliancej' YAHMUU I H HtAL I H Utr 1.
ry;1146 ROUTE 28 0 0
:.. No. � � -49ZI SO. YARMOUTH, MA 02664 �v8 1(o FEE
I MMONWEALTH OF MASSACHUSETTS
` Board of Health, T A A4,t o o -t' � 4�-;
MA.
PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Ap ication for ermi to C ns uct(/� e i �gi andon O - a Complete System CJ Individual Components
Location L s t
Owner's Name 014A4j 6&ad&)AK
Map/Parcel#as Pe L 23 n
Address 3F w ` W
Lot# 3
Telephone# Sd r
Installer's Name
Designer's Name
Address 75t� t/.1
Address 3
Telephone#S-'o d�� s
Telephone# So X36
Type of Buildings 1 dpi Lot Size -Z 73,P sq. ft.
Dwelling - No. of Bedrooms 1164 P o Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) //n gpd Calculated design flow 33 6 Design flow provided 33a gpd
Plan: Date /0? Number of sheets Revision Date
Title _
tion of S5i1o. Test' G� of
P (= 8 --,4F cJs A � a� ^>� = c Fl.�- = J�� L/s /�Y--�E',!/s
Description s) o�,r a6'=_ /�2n o 'e'r —/?n =c�.'�js
Soil Evaluator Form No. Name of Soil Evaluator 1W,4) c u)SdCuB S Date of Evaluation /,/-
DESCRIPTION OF REPAIRS OR ALTAAERATIONSt((�����/=
_7c—.._ ri/ t•_ ...4 -H. 1/ / 1J. ..n �iLs.sA_�, i•. - � _. .i 1. - /� �... .: n -, ': _ � c �r—il_.i. �
t y L.5611- Ae vw4L y% (u i A4 FaR s�q �s, -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to not to place the in in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed tJ�«) - 4412. Date %- %- 7./d -
No. J40 'DC'tg�� E �J�D, 00
�sZ
Board of Health, 14 4 w,4 o b -i` d MA.
CERTIFICATE Of COMPLIANCEff W " .1
�-4�4A9�- a' I
Description of Work: Ll Individual Component(s) (0 complete System QtR .� V�jr, 0k '
The undersigned hereby certify, that the Sewage. Disposal System; Constructed ( ), Repaired( ), Upgraded ( ), Abandoned O
by:
at . 33' �N-�c,is-
has been installed in ccorda e with the rovisionsoT -1-0-CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated " 12- -le. Approved Design Flow 3,U (gpd)
Installer �,� 1� i s C, S5 !.. t t-4
Designer: q&lenprzilIns
The issuance of this permit s iall not be "Construed as ;
guaoi tee that the system will function as designed.
No. (3 C C 'gj- tSZ4 C` �. FEE PO
COMMONWEALTH Of MASSAC14USE
% t�
Board of Health, Y f4 A iM si1r a4...
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; ConstructO Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
atas described in the application for
Disposal Systenr&onstruction Permit No. , dated �2
Provided: Construction `shall be completed within � of the date of this permit. All local con_ ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkln Co. Boston, MA Date i �G ~ r Board of HeA th i� 7 `—