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HomeMy WebLinkAboutApp-Permit-Compliance�q / No. V FEE 10,0 COMMONWEALTH Of MASSAC14USETTS YARMOUTH HEALTH DEPT. B �„ c� / S� oard of Health] 14R R(XT€ �8 MA. APPLICATION FOP, DISP8UMM?WMIRUCTION PERMIT Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) - ❑ Complete System &'li dividual Components Location 392 m a / n A Owner's Name A � `G� nuf L, G /^ Map/Parcel# ;.3, -7 Address p3 /-w Lot# Telephone# Installer's Name �` �}, d Designer's Name Address �� Address Telephone# Telephone# Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage eo l o 13" 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 ORALTERATIONS ''Cri S �► �) 1 S 11- 1401•-f - (1- 6031 14-- Ir) Lric.r'.�,-,n -'r The un"iigrne;�daTgrees to ins a above described•Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furthert ace a sys o eration until a Certific to of Compliance has been issued by the Board of Health. Signed Dated % t, l a �- Inspections No. O �- - � 2- FEE COMMONWEA T14 Of MASSACH SETTS Board of Health, c, l mq. CERTIFICATE OF COMPLIANCE Description of Work: ©-Kdividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, ); Upgraded ( ),Abandoned ( ) r �� has been installed in accordance with the pr vislo k4 310 CMR 15.00 (Titl�5) and the approved design plans/as-built plans relating to application. No. 0 a- _ � � �— , dated t [ f `l0 G -I-- . Approved Design Flow (gpd) Installer 1/ l c J '-4 , irc Designer: Inspector: (%� 0 Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. (C l'C, COMMONWEALTH Of MASSACHUS T (MGc / Board of Health, C � , MADISPOSAL SYSi(4 CONSTRUCTION PEP, C ck./' if., ,,,v Re V Permission is hereby granted to; Construct( ) Repair( ) Upgrade{ ) Abandon-( ) an ' ividual sewage disposal system at as described in the application for I Disposal System Construction Permit No.©)- VVL dated lot / 0 , Provided: Construction shall be completed within three years of the date of th's per ' . Al ocal co tions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / /)/ c/G Board of Health