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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE C� f/' P COMMONWEALTH OF MASSAC14USETTS o i � ;,. YARMOUTH HEALTH © �t.T. Board of Health, 46 ROUTE 28APPLICATION FOP, DISPO�%MqMrMMUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - 9!LComplete System ❑ Individual Components Location Lo0jN Owner's Name Pj1'z ba-mr%cy- Map/Parcel# Address Lot# dL Telephone# Installer's Name `G �� Designer's Name Address is , . ` t 4 Address , 6 IR^64 Sr Telephone# - Telephone# Type of Building Lot Size sq. ft. Dwelling- No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required)33 z) gpd Calculated design flow ,-3 , 0 Design flow provided -� � gpd Plan: Date 1M4r :( LO�, ` GAO Number of sheets ' Revision Date Title_ - Description of Soil(s) `0V0. L-> WA O % 1V%V--V-,- Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS per p � 47- r The undersigned agrees to histall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furthe a system m until a Certificate of Compliance has been issued by the Board of Health. Signed Date s Inspections No. �03 2,l COMMONWEALTH MNEAH C USETTS FEE Board of Health, V p CERTIFICATE Of COMPLIANCE xlvxcl- Description of Work: ❑ Individual Component(s) ")!L Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (+Abandoned ( ) by: D - _ 6 C— at f ti SST o.,r tu'Dt has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and theme approved design plans/as-built plans relating to application No. s .� dated �-, �� f d�Approved Design Flow �3"-�- (gpd) Installer /l�L/',�,�� ��ef �:� Inspector: Designer: Date: sip � The issuance of this permit_shall notybe construed as a guar tee that t e system _will yfunction as designed. _ No. /! �.� / /���Gv':/% FEE COMMONWEALTH OF MASSACHUSETTS Board of Health,\tl, MA. DISPOSAL S ]1ST CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade (Le< Abandon( ) an individual sewage disposal system (J rt at t�-�7.L tU V &2 STT (t) . �1-,v vtn- r( !b I as described in the application for Disposal System Construction Permit No. 'Z dated Provided: Construction shall be completed within three years of the date of this permit. All local jjjconditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ~�� -yy Board of Health /12