HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
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%G A--lw4w.5 Board of Health114' ROUTE 28
%SO. YARMOUTH, MA 0286P.
APPLICATION FOP, DISP®SA� FHM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( )- Upgrade( Abandon( ) - WIClomplete System ❑ Individual Components
Location ,33
W l LLI AM4-1� d
Owner's Name AIEV0
Map/Parcel#
D (0
Address I q j W413 /y VJ "
Lot#
Telephone#Z3
Installer's Name
Designer's Name
Address
m
Address aS (;REA J" KJESJE -t Y CEW
Telephone#
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Telephone#!0 pa
Type of Building IRFL , tca cl [ a— Lot Size O sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 6, gpd Calculated desi n flow Design flow provided gPd
r
Plan: Date 49 10:3 Number of sheets Revision Date
Title C
Description of Soil (s) r1
Soil Evaluator Form No. Name of Soil Evaluator ;SW EJEJ[VX Date of Evaluation o
DESCRIPTION OF REPAIRS OR ALTERATIONS
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The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire j no ty� syste eration until a Certificate of Compliance has been issued by the Board of Health.
Signed j �UI1 Date
Inspections
s�a/` A- 4.4
No.
COMM® ®r
Board ofHealth.
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CEP'Tirp. 'IE or CO
FEE
,MA.
CIAN-CE
Description of Work: ❑ Individual Component(s) Complete System
The andsi ned hereby certify thjat the Sewage Dispgsal System; Constructed( ), Repaired ( ),Upgraded �andoned ( )
by: M C AI t o�I MR1 , 1 N C-
at I"1 D kt
has been installed in cc e with the o_vi 10 s o/0 CMR 15.00 (Title 5) a tl� ved design plans/as-built plans relating to
application No. Q - dated '' / . Approved��D^^esign Flow / J. gpd)
Installer C® Mly
- l_
Designer: ~ IE�G Inspector: Date:LO
/ v
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No. U f %U tJ / lFEE
Board of Health, Y1VM0W?4—,jWA.
DISPOSAL SYSU 'l[ CONSTRUCE® PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at 33
as described in the application for
Disposal System Construction Permit No. V l , dated
��
Provided: Construction shall be completed within6II'lt's of the date of thise it. All local condi 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Q Board of Health
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