HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 7--� Z" Z /� FEE FV
Board of Health, , 1GIA
YARMOUTH HEALTH pp�. T.
1146 ROUTE 28
APPLICATION FOP, DISSMIR"T-MOWTION P IT
Application for a Permit to Construct( ) Repair( . Upgrade( ) Abandon( - ❑ Complete System Individual Components
Location
Owner's Name
Map/Parcel#3
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SG
Address f� f �'S
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Lot#
Telephone#
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Installer's Name
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Designer's Name
Address
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Address
Telephone#
Telephone#
Type of Building 4
Dwelling - No. of Bedrooms
Other - Type of Building
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
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS/ �c-e 04)11e
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreesr}o to place the tem in operation until a Certificate of Co lian' a has been issued by the Board of Health.
Signed D
ate �� / / ,
Inspections
No. 7 -�Z 2— COMMONWEALTH OF MASSAC14USETTS FEE /
Board of Health, ^/l/'dI%iGFJ MA.
CERTIFICATE Of COMPLIANCE T(f 1-0
Description of Work: U4dividual Component(s) ❑ Complete System ;
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( 4."I/jpgraded ( ), Abandoned ( )
by: iU Or7 .J7-'^drTiw
at /-7 r f(r✓ Z/) S �%lacv i
has been installed in accordance with the��rovisions of 310 CMR 15.00 (Title 5) and �-approved design plans/as-built plans relating to
application No. Z Zd/ated // -� 4 7 Approved Design Flow (gpd)
Installer r AA ��% 11r . ,ll
Designer: --- Inspector: Date:
The issuance of this permit shall not be construed as a guarante that the system will function as designed.
No.97 32/ v / ' ' FEE 1 V
F
COMMONWEA1111 Of MASSACHUSETTS
04
Board of Health, yls9d� 7" �' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( (4/Upgrade( ) Abandon( ) an individual sewage disposal system
at 17 /)o,ch - M J e, as described in the application for
Disposal System Construction Permit No. 697^ 2 �, dated
Provided: Construction shall be completed within three years of the date of thi rm t 1 cal conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �r �� / Board of Health