HomeMy WebLinkAboutApp-Permit-ComplianceNo. _ FEE
e Board of Health, YARMOUTH HEALTH DgPr.
APPLICATION FOR DISP A , kp"UCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
S-
Address Thr �jj"
Lot# "p -;�^
Telephone# 1
Installer's Name
��
I
Designer's Name -
Address ��
l
Address G�[� iQd,4-,v71
Telephone#
F-1)(0
Telephone#
Type of Building V e—
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
r �
Design Flow (min. required) '4 40 gpd Calculated design flow �� t3 Design flow provided gpd
Plan: Date 10-0-0 Number of sheets I Revision Date
Title Lm=.
Description o Soil(s) i+M:A.-
Soil Evaluator Form No. Name of Soil Evaluator 1-�V 0 -`r-z V"- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install dw above described Indi ' ual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furth es to not to pl Mysotem m operatto a Certificate of Complianj.ee has been issued by the Board of Health.
„Signed Date ,e l/y
g
- Inspections
i
4
No. / FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, VA(ZM11A MA }
CERTIFICAIE OF COMPLIANCE
Description of Work -&Individual Component(s) ❑ Complete System
The undersigned hereb t the Sewage Dist) o m• Constructed ( ), Repaired ( ), Upgraded � Abandoned O
by:.�Jc
at c --
has been installedinaccordance with the provisions of 310 CMR 15.00 (Titl 5) and the approved design plans/as-built plans relating to
application
7No. /) V - dated �� �-27- pproved Design Flow�(gpd)
Installer/CP�r>l �'C. i�Z>
Designer: Inspector: r 1'� t �- I/.,! i /eCJ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.�////��✓// FEE
COMMONWEALT14®F MASSACHUSETTS � �� � Z cis 6
Board of Health,{N�c -'-N- T ( MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(V) Abandon( ) an individual sewage disposal system
at v v-,::- L,." A as described in the application for
Disposal System Construction Permit No. 0--5- , dated/0 7--
G pxtvS.
Provided: Construction shall be completed within 4w -f rs of the date of this perinit. All local conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date %�) —Z7 X Board of Health L.®0,12 X
-76