HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH utt' 1.
�_�� �\� O . � • SD YARMOUTH, MA 02664 FEE /U ` �-'
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Board of Health, , NU
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(t�/Repair( ), Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location `�
Owner's Name
Map/Parcel# UI
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Address U.
Lot#
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Telephone# &q A J 8 `j _ �9, 7 S
Installer's Name ' e
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Designer's Name
Address y n
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Address
Telephone#
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Telephone#
Type of Building 3i�.�C, (� 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
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS G.� e� ! ✓I s�aJ e 6-e .r�� C .es SD �n) f s "� �7 1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with th provisions of TITLE 5 and
further agrees to not to place the Ustem in operation until a Certificate of C 9mPliance has been issued by the oard of Health.
Signed Date
Inspections
No.
Description of Work:
The undersigned here
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FEE �` i ' C'. ;
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Board of Health, MA.
CERTIFICATE OF COMPLIANCE
"dividual Component(s) ❑ Complete System
ry certify that the Sewage. Disposal System; Constructed ( ), Repaired (,Upgraded ( ), Abandoned ( )
at
has been installed in accordance with the prions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.77,277 `��/' 3 l� datedApproved De ' n Flow (gpd)
Installer t' YrC
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Designer: _ Inspector: Date:"'Ts
The issuance of this Permit, shall not be construed as a guarantee that the system Illfun 'on as designed. 44,
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No. 7 � ) U FEE / ' C `
Board of Health, / �^^ "- MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissionisherebygranted to; Construct( ) Repair (,e. � pgrade( ) Abandon( ) an individual sewage disposal system
at % � c c✓i 'tin U-t as described in the application for
Disposal System Construction Permit No%1-3 10 dated 77 ) g
Provided: Construction shall be completed within three -fe s of the date of this per All local conditi s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -� Board of Health