HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. 1146 ROUTE 28
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSAC14USETTS
Board of Health, , MA.
FEE , V
APPLICATION FOP, DISPOSAL SYSTLM CONSTRUCTION PERMIT
Application for a Permit to Construct() Repair (A. Upgrade() Abandon() - ❑ Complete System LrJ4idual Components
Location 97
-, eo Ci 6-04
Owner's Name 8 cq G /3 "-L�
Map/Parcel#
,6sZ<
Address /J!"t �// Ve-e C, j,cl-,► s
Lot#
-7
Telephone#
Installer's Name
ys�a('�p-� �OtiQ'.�-
Designer's Name
Address
✓n "kor 1. ��
Address
Telephone#
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)
gpd Calculated design flow
Number of sheets
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
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 to place the system in operation until a Certificate of Cygi pliance has been issued by the Board of Health.
Signed `8�J'av __ Date to la
Inspections
No. 'l..®MMONWE ITII OF MASSACHUSETTS FEE A Z-�
Board of Health, NA 6+^^ ,MA. r ! - ,t
CERTIFICATE Of COMPLI �CE
Description of Wdrk: ly'Individual Component(s) ❑ Complete System
Theundersigned hereby certify that the Sewa e Disposal System; Constructed ( ), Repaired s/�Upgraded ( ), Abandoned ( )
by G�4 O�j `'� l ( Y -r n G-N , 2 L / S lee S c S n9r..1 h Ti•� fi;b ,��
at C1 c, Ci -c �P S LA,-,,,,, L^
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. %7 dated aa ' Approved Design Flow (gpd)
Installer , /1, s g�� cc r1SV n
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. _ <y v [� s FEE /yL • �i
COMMONWEALTH Of MASSAC14USETTS
Board of Health, Mil ✓ ' l MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( Upgrade ( ) Abandon ( ) an individual sewage disposal system
at Ora* * P `P Ci \l' ( )--e .S C y rz\ as described in the application for
Disposal System Construction Permit No. / �7—3 dated =�
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255,11 1 5/96 A.M. SWkin Co. Boston, MA Date -� ^� oard of Health
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