HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
lirc } 7 1 146 ROUTE 28 FEE � - ` � �
Nc, SO. YARMOUTH, MA 02664
COMMONWEALT14 Of NASSAC14US ETTS
Board of Health, �1 �Y , MA.
APPLICATIO�T FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(6YUpgrade() Abandon() - ❑ Complete System 6 dividual Components
Location ff(/'/V t T jO�f i yQ $ so
Owner's Name <J 4� "7L—s
Map/Parcel# 6
Address 0,6 fits ( AIZ S/o.vZR 5a Y,je
Lot#
Telephone# -5-0 - 3 ,F8-- 4 V 97
Installer's Name 4416 oh4lb1h o
Designer's Name
Address 3 ,5�G olVfAl -5 % Div
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
o1/s ;E
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS ok/ V C C lT,O'c"A £ w0a's E —7'; -
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to not to place the sys m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. �j` t�� FEE �
COMMONV'1' EALT14 Of 1` ASSA'L_ HUSETTS • �
Board of Health, Ye-u MA.
CERTIFICATE Of COMPLIANCE
Description of Work: YIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired YX), Upgraded ( ), Abandoned ( )
by: i (1/7y c 0 -3 .S a .S/ �,/ Ly -
at O U 4/Z S/0-V Z Q� S O T l/e
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. da I U Approved Design Flow (gpd)
Installer
Designer Inspector: Date: �d l
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
I
Board of Health, Y� ✓ MA.
➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT
r
FTeE _.
Permission is hereby granted to; Construct( ) Repair(y Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 16 OyN l •f oy r- So f ' /e as described in the application for
Disposal System Construction Permit No. t�5—�a-% dated /v
Provided: Construction shall be completed within (thhree years of the date of this permit. All local con tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date) Q -) U Board of Health