HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 28
SO. YARMOUTH, MA 02664
FEE C
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Board of Health, A.
AVI11CATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ), Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location C I �� �� W� �`` �i ��
Owner's Name
Map/Parcel#� M Z�
Address
Lot# C ' eto S
Telephone# S`o 8
-2 G 73
Installer's Name
Designer's Name
Address �AA4OI.
Address
Telephone#
Telephone#
Type of Building e9 \,9- Lot Size sq. ft.
Dwelling - No. of Bedrooms Z Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
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
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS iGP_LA eV c-(-_ -�
gpd
The undersigned agrees tokr4all the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s ace a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 6 " 7 - / 7 -
Inspections
No. - ,�S FEE
'L_,®MMONWEALT14 OF MASSAC14USETTS
Board of Health, T li 1LOlrl I MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (/Upgraded ( ), Abandoned ( )
by: VN VL
at ! I
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. `.-)- , dated Approved Design Flow (gpd)
Installer �A -21C0_\J\ « I ____1 ly
Designer: `- Inspector: "<r—
The issuance of this permit shall not be construed as a gu ntee that the system will function as designed.
No. FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (CKupgrade ( ) Abandon ( ) an individual sewage disposal system
at [ I UJ I (\ .D M L-- (0 �j A-{ n J l ji as described in the application for
Disposal System Construction Permit No. dated % 7�
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
" y 9 Board of Health
Form 1255 Rev. 5/96 A.M.nSulkin Co. Boston, MA Date / ..