HomeMy WebLinkAboutApp-Permit-ComplianceNo. -Jf-� FEE .5�.
COMMONWEALT14 OF MASSACHUSETTS
YARMOUTH HEALTH DEPT.
Board of Health,l 146 R-�m rm , MA.
APPLICATION FOP, DISPMAMMTOMUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( )- Upgrade() Abandon() - ❑ Complete System individual Components
Location ZI- C
C
Owner's Name
Map/Parcel#Address
Lot# Z t�3
Telephone#
Installer's Name 0- 1G•
L
Designer's Name
Address 7-7 ow,,J
ak-669 I&S W,
Address Z3 -1 -6A -,E41-
Telephone# o �%7
D
Telephone# 0
Type of Building �e 5t d �,Jc� Lot Size /Zo a o o sq. ft.
Dwelling - No; of Bedrooms Fa yi@ Garbage grinder (w)p
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) //0 gpd Calculated design flow Y ,�, 0 Design flow provided V43, y`� gpd
Plan: Date 3 - Z 6 - 0 1y Number of sheets Revision Date
Title
Description of Soils) o �,/ L ��� Zn "y s4aj9 Zy iii LoAu.t!e 5 4(� Z!g /t Sl G u.teA t1 S4-)4
Soil Evaluator Form No. Name of Soil Evaluator 10 r4d %/e2T Date of Evaluation 9 - 25— 0 �V
DESCRIPTION OF REPAIRS OR
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed C. Date
Inspections
No. �/ / -� FEE SD O O
Board of Health, Y 4A, -w, ,, 4 U , MA. V -
CERTIFICATE OF COMPLIANCE
Description of Work: "dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded O, Abandoned ( )
by: F C 1 � , s3 L t,JG
at Zr C4 6 .t -u1 i� / C ►off kg A kb A V
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 `41% t, Approved Design Flow li 63 , V!(gpd)
Installer
.C.
Designer: C',,!t S r.� y. �(� Inspector: Date:
The issuance of this permit, shall not be construed as a guarantee that the system unction as designed.
No. d'- f� FEE�a - O
COMMONWEALTH Of MASSAC14 SETTS
Board of Health, ,4 Q u i,a •� t AL4•
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(] j Repair( ) Upgrade (>,) Abandon( ) an individual sewage disposal system
at Z CA P l d k LA k,6 as described in the application for
Disposal System Construction Permit No. t -Y -164, dated - �`2- 7 e)
Provided: Construction shall be completed within of the date of thisermit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date F / Board of Health �(°f