HomeMy WebLinkAboutApp-Permit-ComplianceNo y FEE
COMMONWEALTH OF MASSAC14USETTS
YARMOUTH HEALTH DEPT.
Board of Health,.
APPLICATION FOP, DISP®RRJMMM �69"UCTION PERMIT
Application for a Permit to Construct( ) Repair(x} Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location vj r Lie 5
Owner's Name fGhc-t (1SG r
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name ry 6'( t '�
Designer's Name
Address / 1' 70n I{ /5
Address
Telephone# -� L - 1-1 �
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.
`7 -2 yi S 3C -8&70
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
gpd
DESCRIPTION OF REPAIRS ORALTERATIONS
l � I �ti"1r� .�iG 1, �/�► � S?A 1 / 1--� 5 �- ��S � � �- /� �Sz �� -' ' r-c �r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furth r a e not to place a tem in o erati until a Certificate f om li ice as been issued b the Board of Health.
Signed Ems_ ^ 1 p Date 7 . y
Inspections
p�_i�i
No. COMMONWFALT14 Of (`j��U FEE t
SETTS
Board of Health, ✓ n,c MA. a
Description of Work: 8 Individual Component(s) ❑ Complete System
Trh�-Jersigned herek certify that the
ff Sewage Disposal System; Constructed ( ), Repaired (X), Upgraded,(-. andoned ( )
. ` by
at
has been installed in accordance with the provisions o_',310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application,NoP& �-� i�" dated Approved Design Flow (gpd)
Installer 0' 1 G n ( i
Designer: `^-^--^ inspector: Date: Q
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. v FEE
Board of Health, Y �+- °'i"�" MA,
f`
DISPOSAL SYSTEM CONSTRUCTION PERM
IT
Permission is hereby granted to; Constr ct( ) Repair (X )' Upgrade ( ) Abandon ( ) an individual sewage disposal system
at-5 lv ry C� `\ as described in the application for
G
Disposal System Construction Permit No 0 yl� dated '
Provided: Construction shall be completed within three years of the date of this emit. All��cal conditions must be met.
l "� ,'
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �U Board Of Health