HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE ✓(sgr
COMMONWEALT14®f MASSAC14USETTS ,4616 %
YARMOUTH HEALTH DEP'j'�
y Board of Health] MA.
APPLICATION FOR DISP®9A?1RUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( - 21 Complete System ❑ Individual Components
Location
v
Owner's Name flftrm 9q, 4
Map/Parcel#
-TV 54
Address o4j C � ��
f
Lot#
117
Telephone#
Installer's Name e r a,�
Designer's Name3)14
Address
P. V 3 L
Address 03 �}
Telephone#
60
Telephone# –IC6)
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. r quired c b� gpd Calculated design flow
Date
Plan: I Number of sheets on-�
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR
3 -IL-11,13 .0
Name of Soil Evaluator
1600 6X
`�)/>( )DLA It
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided "' gpd
Revision Date
Date of Evaluation
A,
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 lace a tem in operation until a Certificate of Compliance Jias een issued by the Board of Health.
Signed Date 5"
Inspections
No. C.' FEE
C. OMMONWEA TH Of MASSAC14USETTS
Board of Health,' � ! m AM. j(�!
CERTIFICATE Of COMPLIANCE
Description of Work: -0 IndividualComponent(s) .. ff'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepairedUpgraded ( ), Abandoned (
by: ` ylf "r,r thy. /�/^
at /4J ! c7r .,. C�yJ. rv'hQnlX4 "�♦�iVX lW7 �/
has been installed in accorda e with the provisignIs of 310 CMR 15.00 (Title 51 and t e ap roved design plans/as-built plans relating to
application No. � _, dated
.Approved Design Flow = gpd)
Installer
Designer: 4-t'' c �� 44 t Inspector: A4&4e L/ Date: '
The issuance of this permit shall not be construed as agu ai7dutee that' a system will function as designed.
No. FEE
COMMONWEALTH Of MASSACHUSETTSto
Board of Health, ,NIA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby ranted to; Construct( ) 'Repair (7^) Up ade ( ) . Abandon ( ) an individual sewage disposal system
at 1,3 k, 1..:�h4✓ln. Y, J
-�Alr� 1)1— as described in the application for
Disposal System Construction Permit No. , datedY
Provided: Construction shall be completed within ti so
the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin.Co. Boston, MA Dat —1,7-&,7 4 -Board of health