HomeMy WebLinkAboutApp-Permit-ComplianceNo. SG/ �% FEE
Board of Health, YARMOUTH HEALTH DPAT.
APPLICATION FOR DISPOWY9jWW, WORUCTION PERMIT
Application for a Permit to Construct( ) Repair (VKpgrade ( ) Abandon( ) - omplete System ❑ Individual Components
Location
Owner's Name `
Map/Parcel#
,/ 6_�,
� � ��
Address '�2_
Lot#
Telephone#
Installer's Name
Designer's Name
Address JeM4
�L�3
Address —
Telephone#
I% --
--
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures 99
Design Flow (min. required) �-Z<-- 6 gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) e�.�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree
A to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
/I V
Inspections
No. ` / FEE
Board of Health, MA.
CERTIFIC®F ,COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
by:at
has
Installer
Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Board of Health, DISPOSAL l MA.
FEE ZO
:K/2/2
Permission is hereby granted to; Construct( ) Repair( J.)" Upgrade( ) Abandon( ) an individual sewage disposal system
at a _ ���-- bra as described in the application for
Disposal Syst Construction Permit No. dated //
6AA" S
Provided: Construction shall be completed within ors of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �iZ�OJ Board of Health '