HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. t 1146 ROUTE 28 FEE �b
6WZ81'� 70 C® 0WR"N- SSACHUSETTS L
�P���Board of Health,WMA.
ION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( )_ Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name Si
Map/Parcel# y- - L..
Address
Lot# O
Telephone*
_.
Installer's Name V rN l �5-
Designer's Name
A4 0t, 606-E7,S Est? T'°Lq q
Address b ly
Address 900
2Te l3 1!f/S S,10Grtiaj451M4 azwa
Telephone#
Telephone#
-68D 38:5 - (,5'3Q
Type of Building izt),i dtn-'1 1 Lot Size sq. ft.
Dwelling - No. of Bedrooms (`2 e- Garbage grinder ( )
Other - Type of kuilding _ _ No. of persons _tA Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 gpd Calculated design flow d
Plan: ))ate QQ - 9 9 Number of sheets 1
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS ORALTERATIONS IVY. .0)AYN
Design flow provided
Revision Date
gpd
Date of Evaluation l I - o a - 'All
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e t not lace th tem in operation until a Certificate of Cc li has been issued by the Board of Health.
Signed nymm Date
.
^,Inspections
No. ? FEE
COMMONWEALTH ®F MASSAC14US ETTS
Board of Health, t)�MWA� C
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The ud herec�er�tif�ypt�h/at�the/S�ewageyDPp
OM
osal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by:
at E
has been installed in accordance with the provisions o 310 CMR 15.00 (Title 5) and the pp oved design plans/as-built plans relating to
application No. �� , - p7�3 �, dated
�®�� Approved Design Flow and
Installer I'pl�R /vim WM V le l �I UF,5 1_hp -
Designer: 1174yG Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. JD -0 ez// / FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Yb YM Cr'1ii4/�
MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( /"Abandon( ) an individual sewage disposal system
at �G� as described in the application for
Disposal System Construction Permit No. e- -7-3', dated 2 /-G0
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must bmet.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat t� B Health �C�l
,•.-. s /,f 77- /.4- /A