HomeMy WebLinkAboutApp-Permit-Compliancer YARMOUTH HEALTH DEPT.
N9, -L547 2— — 1146 ROUTE 28 FEE
W MWMM 6MASSACHUSETTS ,j44A
Board of Health, , MA.
APPLICATION FOR DISPOSA YSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ❑ Complete System W'individual Components
Location :3S E
Owner's Name r Lon 0 rx f4
Map/Parcel# LA a o /
Address A6`
Lot# io 1
Telephone# 1
Installer's Name `XZ),_G
Designer's Name 4
Address 1 , K3
Address vs -1 ,-- 4s s
Telephone#
Telephone#
Type of Building 6`' S% d� �p u� � 4- V- 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 n �- , 9S
Title
Description of Soil (s)
gpd Calculated /design flow _ Design flow provided QV gpd
Number of sheets / Revision Date
Soil Evaluator Form No. v Name of Soil Evaluator ti -V w A-C� Date of Evaluation rlI&f t- o'er 1
o
DESCRIPTION OF REPAIRS OR ALTERATIONS P -e- o \ w t' S
t' The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
r fur ees to not to ati a Certificate of Compliance has been issued by the Board of Health.
r
z Signed Date
Inspections
_ r:
No. C®�9[I�9 ONWEALT14 Of MASSACHUSETTS � FEE �_
Board of Health, 1A 'z Y,\DMA:
CERTIFICATE OF COMPLIANCE
Description of Work: individual Component(s) O Complete System �
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded , Abandoned ( )
by: c \4 PES P\\C-
athas been installed in accordancewiththe provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. `� �! �- /dated 6 4� F Approved Design Flow (gpd)
Installer l%//S 567'02 C.
Designer: Inspector: i!5�'Is2A TS 6- ."f Date: ! 1%
The issuance of this permit shall not be construed as a guarantee that the system 14 function as designed.
No. 2-7 Z- s/J'�//� �1�j�y�. C. FEE
Board of Health, c.�ir'ra /rl� , MA.
DISPOSAL SYSTEM CONSTRUCTIONPERMIT
Permission is hereby granted to; ConstryA t( ) Repair ( ) Upgrade ('Abandon ( ) an individual sewage disposal system
at --7:?.e V",,,e- v-'- . N (/\ (e. VA- as described in the application for
Disposal System Construction Permit No. ��l `.�. `l' Z dated 6 Z.3 %�
Provided: Construction shall be completedwithinthree years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 6 Board of Health