HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEAL M uhri.
No. 1146 ROUTE 28 FEE
SO. YARMOUTH, MA 02664
C �r s� i-�OMMONWEAICT11 Of MASSACHUSETTS
Board of Health, L Q 0", MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name A 0 03 el—`f Crow --7 ,e
Map/Parcel#
j-4---> 17
Address 9 c 3 ® cu -m
Lot#
7
Telephone# SCv,�- F -7J -6 6 ST
Installer's Name �_ l
�� �' � C'o,-, s'.-
Designer's Name /Lon y l � C7W
Address fJ
/L
Address .0. 6 GJ ;L s f _Li (may
Telephone# 3U _
Telephone# 7�Q
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
Garbage grinder
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)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 agr es to not t�(' q jare e`system in operation"until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No.
Board of Health, �% p �-✓i (1 P4 ri l MA.
CERTIFICATE OF COMPLIANCE
FEE
.rl
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: C f C ov w t'Y-
at Z G Ste, ( 5 n.,'rt-y A of VG, "/.I
v
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5)
application No. 9 �/ -�'1 i1, dated A - 3 / . Approved Design Flow
Installer 1, t R COT,, P r.f , CO,7S,} , G,
•oved design plans/as-built plans relating to
(gpd)
.Designer: R c n �y t 11't L Inspector: t!" t Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALT14 Of MASSAC14 SETTS
Board of Health,v H h , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE �-
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at j (0 Scj (, m r ry P d L/. , P as described in the application for
Disposal System Construction Permit No. �1 �, dated'- c
Provided: Construction shall be completed within thnee,years of the date of this per it. All local ccoon)didons must e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �/. Board of Health CJ
!. j /°i / �—r� irx /.ate`✓ ''l 7` 7l !.--f=7'i�%�/%/