HomeMy WebLinkAboutApp-Permit-Compliance_ YARMOUTH HEALTH DEP U.
No. _� 1146 -ROUTE 28 rt ;
''SO. YARMOUTH, MA M604
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
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FEE
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( )- Upgrade(/Abandon( �komplete System ❑ Individual Components
Location '` i 5 o� r ��,
Owner's Name T t' 1 Y\� C
Map/Parcel# 6----0 A16:2j
Address
Lot# ^5 —c3�.. _ /4' t l 9�? /y />
Telephone#
Installer'sName Ak, i) --c—Ap F-- 5.7 0-1% C—
Designer's Name
Address l \d✓: � '` � S
%� - n �n
Address -7 11J>o�((�'QO� K� S4J-0
Telephone#
Telephone#
Type of Building \`J `t ��•� 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)gpd Calculated design flow Design flow provided d
Plan: Date a --�, `a� Number of sheets Revision Date
Title —t— t MIM\ Al S
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the ab ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furl, a tem in o til a Certificate of Comp�liantee has been issued by the Board of Health.
Signed Date
Insp',cdons
No. 60 - / / i^ FEE
COMMONWEALTH,
COMMON��H OF MASSACHUSETTS
Board of Health, MA.
CERTIFICAA ®r COMP NCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The, undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (1/S Abandoned O
by: `
at 2S;T'
has been installed in accordan e with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated -? -/0 'G'C/ Approved Design Flow' - (�pd)
YZ W
Inspector• tAI!A s moo'
Date: Ll—)LJ-00
The issuance of this permit shall not be construed as a guarantee thaf1he system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ,,JX MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade (W --Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No. �1 �, dated �` r
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. l local conditions must e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat �~ � Board of Health
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