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HomeMy WebLinkAboutApp-Permit-ComplianceNo. !♦ < �� FEE .�® oJe6l COMMONWEALTH O�, MASSACHUSETTS Board of Health, YARMOUTH HEALTH DWAT. PPLICATION FOP, DISP®SA- L,� S STU'Mi • C�ONSIRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location S� Z Q Owner's Name ©,,41 t If f ell ONS Map/Parcel# fP, Address x R� �v Lot# Q 6 Telephone# Installer's Name T 67Rz S -ON Designer's Name Address �/1/��e/Q� /e Address Telephone# % S 9.5 3 9 Telephone# 3 r �` -45, J" 3 0 Type of Building Dwelling - No. of Bedrooms Other - Type of Building — Xe2 Other Fixtures Design Flow (min. required) 3 3 d Plan: Date OZ – Title /0✓ f CS Description of Soil(s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS ORALTEI The undersigned agrees to install the ab further agrees to not to place the syster SignedP 9V P, Inspections I Lot Size 91 3 9 6 sq. ft. Garbage grinder ( ) No. of persons w" Showers ( ), Cafeteria ( ) 5L�,.;I;4 - r Z7 X Design flow provided �o ' �✓ gpd .evision Date ----� - Date of Evaluation 4K11-0 '99 ordance with the provisions of TITLE 5 and :n issued by the Board of Health. No. C 1 O FEE COMMONWEALTH Of MASSAC14USETTS Board of Health, i/ AX E O 611'11 meq, CERTIFICATE OF COMPLIANCE Description of Work: 'U-<dividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: at .` Z '�1 �1Gf' ` 25) /�7 / b'e has been installed in accordance with the p vis' ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow 3�!`0 (gpd) Installer _ }�• i.O, Designer: P* --k S Onle,— , Inspector: , Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. ,4 No. p� M� – FE COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. ` DISPOSAL SYSTEM[ CONSTRUCTION Permission is hereby granted to; Construct( ) Repair( L�. pgrade ( ) Abandon( ) an individual sewage disposal system at i �' ze- as described in the application for Disposal System Construction Permit No. U 1 l , dated V&//o J Provided: Construction shall be completed within dirc,.ywars of the date this er i 1 local nditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 4At,& Board of Healt