HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEAL I H utr i .
No. � 1146 ROUTE 28
So. YARMMOUTH, MA 02664
COMMONWEALTH Of MASSACHUSETTS
Board of Health, At Ulti MA.
FEE 1-5-0
/ook'� ,443 714
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( <Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location oZ o HA ,r ,
Owner's Name n { r
Map/Parcel#
Address 3 pa rrq L) ;VX
Lot#06.t>
Telephone#
Installer's Name f 3 �� xjco
Designer's Name Li-cx— S c r �Yl
Address 5 D
Address E.
Telephone# j - 2 �y
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 3 3y gpd Calculated design flow
Plan: Date 3 ' oZ S O o Number of sheets
Title 1< r C `I< 5 i c rj
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers( ), Cafeteria ( )
Design flow provided ?5J gpd
Revision Date "L) ZA
Description of Soil(s)
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 agrees to not
�toj lac a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed `VAA 4 Date S ' g `0-0
Inspections
No.y" �,� 7 � �(' FEE
COMMONWEALTH O MASSACHUSETTS
Board of Health, YG41ym MA. f!
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) C'1 Complete System �S- ell all,
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.�-, pgraded ( ), Abandoned ( )
by: - C
at
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. 670 _-2� Z-, dated C,- Approved Design Flow (gpd)
Installer
Designer: Inspector: Date
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.r
No. . C11 P-116 V FEE U
COMMONWEALTH OF MASSAC14USETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Co struct( ) Repair(w<bpgrade( ) Abandon( ),an individual sewage disposal system
at C o A/4 c, Q l i t t/ �C�i/i� "� , as described in the application for
Disposal System Construction Permit No. (/ :2,.i 2- .,dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 1/w oard of Healthli