HomeMy WebLinkAboutApp-Permit-ComplianceNo. 10- __�(02 %�40 ,m FEE So .,--
A - COMMONWEALTH OF MASSA ETT
�j YARMOUTH HEALTH
Board of Healtht 1 65 ROUTE 98 MA. Y'
I I
�U - APPLICATION FOP DISP8S9R"WMT1RUCTION PERMIT
plication for a Permit to Construct( ) Repair( pgrade() Abandon() - ❑ Complete System ❑ Individual Components
Location ff/yJ
Owner's Name e�rh,'
Map/Parcel#
Address
S.411'�
Lot#
Telephone#
Installer's Name
Designer's Name
Address 350 Main Street
Address
Telephone# W.Yarmouth,
Telephone#
3 G oZ - a
Type of Building / \c Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required 330 gpd Calculated design flow Design flow provided 3 3 gpd
Plan: Date �O % Number of sheets Revision Date
Title _rM —
Description of Soil(s) Per L' k-Aj
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I C F
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n t pla�t system in operation until a Certificate of C mplia ce has been issued by the Board of Health.
Signed Date 3,102 i
Inspections
No.
OMMO
Board of.
C EP1
FEE
LT14 OF MASSACHUSETTS
r al�lav h MA.
CAK OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System r,
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
by: / c_.� )C j
at i7�z�t7 . f
has been installed in accordance with the,Provisions of 310 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No.�6?.2^ — ..5- dated iS —26 C.Approved Design Flow (gpd)
Installer
Designer: Inspector: Date: ,��J r -,o
The issuance of this permit shall not be construed as a guarantee that ie system will function as designed.
No. C.'sue.✓ FEE • S �✓ ^
COMMONWEALTH OF MASSAC14USETTS
Board of Health, !??0� )_ MA.
n ,
➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ranted to; Construct( ) Repair( Upgrade( ) Abandon( ),an individual sewage disposal system
at as 'described in the application for
Disposal System Construction Permit No. Q, dated 'ZED Q2--
Provided: Construction shall be completed within tUL of the date of this pe t. All local conditions must be met.
Form 1/255 T Rev. 5;96 A.M. Sulkio Co. Boston, MAAJ Date V —.),_6 �_Inoard of Health "7 Z ✓-
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