HomeMy WebLinkAboutApp-Permit-Complianced FEE G V y V C!
COMMONWEALT s�
Board of Health, 1146 ROUTE 28 , AM. Cka
SO. YARMOUTH, MA 02664
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(o-<iepair( )- Upgrade( ) Abandon( ) - MrGomplete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# J LILY a
Address /6; y
Lot#
Telephone#
Installer's Name
Designer's Name
Address
Address
Telephone#
Telephone# 996 8
Type of Building S �� F-z wt l 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) gpd Calculated design flow Design flow provided gPd
Plan: Date Number of sheets Revision Date
Title
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 describeddndividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o o o place
// systemj"peratpoi til a Certificate of Compliance has been issued by the Board of Health.
Signed �l�t.k L Date Z
Inspections
i
No. o4 W FEE
COMMONWEA T14 Of MASSACHUSETTS
-62
Board of Health, � MA. ( ;
-7 -,� CERTIFICATeOF COMPLIANCE
Description of Work: 0 Individual Component(s) Ek6omplete System
The undersigned hereby'cetify that the Sewage Disposal System; Constructed ( Repaired ( ),Upgraded ( ),Abandoned ( )
by:
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. dated . Approved Design Flow-(gPd) •' ;
Installer 1,14,S
Designer: `i' Inspector: Date: 4 —
The issuance of this permit shall not be c n ;trued as a guarantee that 4 e system will function as designed.
FEE s • (/(
V Board of Health, [- yl--7 , AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT,
Permission is hereby granted to; Construct(,+ Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at %f Eg;�T°1���/� 0!�?>� as described in the application for
Disposal System Construction Permit No. 4 ,�d_ated
Provided: Construction shall be completed within tbx a�&of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date '�- \-�?-'- Board of Health /