HomeMy WebLinkAboutApp-Permit-ComplianceNo. L1i/< FEE
YARMOUTH HEALTH DE[�'j'.
Board of Health, MA.
APPLICATION FO DISP TA M." UCTION PERMIT
Application for a Permit to Construct( ) Repair(11-�UpgradeO Abandon( - ❑ Complete System &15 di;dual Components
Location 3
K c-e -e,
Owner's Name nr C, 01(\ S rv\ 1 'F-'�
Map/Parcel#
S6 pt (
Address a 3
Lot# '7
Telephone# 3 O
Installer's Name
QRS e0"L 0
Designer's Name
Address
O 4hC* S. f
Address
Telephone#
Telephone#
Type of Building `fit Q \ J e &x- a...Q, 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)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to inst a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree o p e e s tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date i - / 8 Zo 0 0
Inspections
Board of Health, '-/A r7., v\,%, o `, MA.
FEE
CERTIFICATE OF, COMPLIANCE
Description of Work: alndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (graded ( ), Abandorf6d
by: R 2�- C 0 M
at 1 3 Kam`! L �_ �� C�-y
C-
has been installed in accoidaV.ce with the provisio s of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated 8- Approved Design Flow (gpd)
Installer
Designer: �- Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
Board of Health, `�'A� L wN o MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( (Up&rade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. 6t
_ 2 7S , datedss/
Provided: Construction shall be completed withiin thr � `f�th %ate of this per .t. All ocal cond'tions must met.
XF. 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 77��/ �/15oard of Health