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HomeMy WebLinkAboutApp-Permit-ComplianceNo. _ YARMOUTH TH HEALTH DEPT, FEE �C®Ml�l'l[4. W4)� CHUSETTS /vim ' / Board of Health, , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair (",(Upgrade( ) Abandon( ) - ❑ Complete System lT-ndividual Components Location lit C � A 1 d 5T Owner's Name Map/Parcel#�P/ /, Address Lot# J5.3 Z ji� Telephone# Installer's Name' (, YZ Designer's Name Address 14A P wICd Address Telephone# 3 Q Telephone# Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Design Flow (min. required) Plan: Date Title Description of S©il(s) _ Soil Evaluator Form No. No. of persons gpd Calculated design flow Number of sheets DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Lot Size sq. ft. Garbage grinder Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not t :ce the s stem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date /j2 — / e1 • C% Inspections No. 6/ - . ,FEE J v ' ✓' COMMONWEALT14 Of MASSACHUSETTS Board of Health,/ e1,V / MA. CERTIFICA A OF COMPLIANCE Description of Work: l Ylndividual Component(s) ❑ Complete System The unde�ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( ) by: ` I 1 V at Y I psi,, "r' -I / Yt) ST S\—/A R "Qs v.( ,A—, been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.e dated ��^ O/ . Approved Design Flow �— (gpd) Installer �! . Designer: Inspector: 1 Date: 1 U The issuance of this permit shall not be construed as a, guarantee -.that the system will function as designed. No. Q ��Li r C/r� FEE ,- COMMONWEALTH OF MASSAC14USETTS Board of Health, _ MA. DISPOSAL SYSTEA CONSTRUCTION PERMIT Permission is hereby granted to; Construct ( ) Repair (/j Upgrade ( ) Abandon ( ) an individual sewage disposal system at `T—\l )'1il )0 1 N SG `IA RYu GUT -1 as described in the application for Disposal System Construction i'er'mt No. dated -� s'. Provided: Construction shall be completed wi hind of the date of this pe i . All loca onditions must be met.' Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date )S U t Board of Health /-- "-) -A / C�