HomeMy WebLinkAboutApp-Permit- Compliance7 YARMOUTH HEALTH DEPT. }�>
1146 ROUTE 28 FEE ®' v
SO. YARMOUTH, MA 02604
7DCOMMONWEALTH Or MASSACHUSETTS
Board of Health, , MA.
-APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location g 7'
f {9- "jt4- rj Owner's Name �i,% �$C, ybp
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name Z
S� �`L Designer'sNamerV,�Cq ly�tolo,i�
Address,:.>D g jq� tj
Address
Telephone# N;- oto ekq
Telephone#
Type of BuildingLot Size sq. ft.
Dwelling - No. of Bedrooms to Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow — Design flow provided gpd
Plan: Date 7 Number of sheets � Revision Date 7o d
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
,
Date of Evaluation /0 ` T6
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreeg to not to em' until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
r
No. � FEES•
G(� v
Board of Health, ay- MA.
CERTIFICA OF COMPLIANCE
Description of Work: ❑ Individual Component(s) .Complete System �,--
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( )
by: S 1� P -\S
at
has been installed in ccordance with the provisjons of 3310 CMR 1 . 0 (Title 5) and the approved design plans/as-built plans relating to
application No. .3�.5, dated - �a . Approved Design Flow 7Qt(gpd)
Installer+
Designer: PO'2l/A,1 Inspector: � � Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. / [il l ✓1�s- /�� FEE,-
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COMMONWEALT14 OF MASSACHUSETTS
1
Board of Health, 4 1AZ Dy72% , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade 94�.. Abandon( ) an individual sewage disposal system
at cp
Disposal System Construction Permit No. / —jw , dated
J20 %rT as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met
Form 1255 Rev, 5/96 A.M. Sulkin Co. Boston, MA Date F Board of Health