HomeMy WebLinkAboutApp-Permit-ComplianceNo. OZ Z" " FEE LS 6
COMMONWEALTH Of MAS W�ETTS
;AV .
YARMOUTH HEAL
• Board of Hea"f1,6 ROUTF- 98 , MA.
'74
APPLICATION FOP, DISAMTKW-t6 STRUCTION PERMIT
Application for a Permit to Construct( ) Repair(0115pgrade() Abandon() - ❑ Complete System ❑ Individual Components
Location
Owner's Name
/�7Z2 •G/'L�
Map/Parcel#
l� —� a 7
Address
Lot#
Telephone#
Installer's Name
A A 8 CANCO
Designer's Name
Ot�Jn
Address
350 Main Street
Address
Telephone#
W. Yarmouth, MA 02673
Telephone#4,1
. -L �/
Type of Building l 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) '7 7 gpd Calculated design flow Design flow provided �7 .S^S^ 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 OR ALTERATIONS /-� r /? /Ax,
The undersigned agrees to install bove described•Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not`t Pi ce the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed V Date oZ
" Inspections
No. FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, MA.
C EPITIFIC EI O COMPLIANCE
Description of Work: Ll Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (graded ( ), Abandoned ( )
by;
at l
�i t -Cr �YC.4.:
has been installed in accordaijce with the provisions of 310 CMR 15.00 (Title 5) and the approved, design plans/as-built plans relating to,
application No. .2 - dated �"'"�4. �� Z'• . Approved Design Flow T (gpd)
Installer (11/17 L &o of A
Designer:l }my�(.0 C -/VC f_W641, Inspector 6V1, X Date: % 7,77- U.
The issuance of this permit shall not be construed as a guarantee tha the system will function as designed.
No. .G - CC 10 FEE .. J
COMMONWEALTH OF MASSACHUSETTS
Board of Health MA. rJ
,
DISPOSAL SYSTEM CONSTR CTION PERMIT
Permission is hereby grantedto; Construct( ) Repair(-- Upgrade( ) Abandon( ) an individual sewage disposal system
at U A-6 4( f 1A "� as described in the application for
Disposal System Construction Permit No. �% Z��, dated
Provided: Construction shall be completed within the date of this p 11 local condition must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date f r (i ) 4oard of health