HomeMy WebLinkAboutApp-Permit-ComplianceNo. 7Qizr
Board of Health,
YARMOUTH HEALTH DEP..
MA.T
APPLICATION FOP, DISPMATA�49VM"MUCTI®N PERMIT
FEE"
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System ❑ Individual Components
Location 4�'
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Owner's Name 5-7-6/
Map/Parcel#
Q 6
Address
Lot#
Telephone#
Installer's Name �� C /y S, y^
Designer's Name��� �- 2
Address
Address
Telephone#
s `T % 3 6 2
Telephone# d ��
Type of Building l L Cc- Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. re uired) '30 gpd Calculated design flow
Plan: Date Number of sheets `7
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Design flow provided /L gpd
Revision Date
Date of Evaluation
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 the system in op on til a rdficate of Coi lianc ,has been issued by the Board of Health.
Signed Date
Inspections
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health� ,- Dv rMA.
CERTIFICAT
�-1 Of COMPLIANCE
- EE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:dL e / f e5�, .,/. S 'r
at Z z /� E Z -
has
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d
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. 1�/ dated ^ `l �i Approved Design Flow (gpd)
_t (. A
Installer L �--
Designer:/,>46' h i2�G�l'i/%' Inspector: Date:
The issuance of this permit shall not be construed as a guar tee 'thal the system will function as designed.
No. l/ /2{t/���' d FEEL
s
C®MMONWEA((l,,LT14 OF MASSACHUSETTS
Board of Health, P'10 /L d" Dy t MA.
DISPOSAL SYSTEM CONSTRUCTION -PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at !� 2 x7,2 E a --a2 / v �� as described in the application for
Disposal System Construction Permit No. 7!/ dated1d
Provided: Construction shall be completed within •S f the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date (/ � oard of Health