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HomeMy WebLinkAboutApp-Permit-ComplianceNo. _ � klale Owl FEE COMMONWEALTH OF MASSACHUSETTS YARMOUTH HEALTH DEPT. Board of Health, 1 1 4C ROI JTF 2A ; MA. APPLICATION FOP DISPOS1?' MN VTMCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components ei Zn LocationOwner's Name d-_kAl N46 Map/Parcel#3 / Address 0/w it, (Oft� Lot# Telephone# © a Installer's Name Designer's Name AddressKOM, e U`-' Address it V Telephone# _ Telephone# Type of Building O�AJ &Vslg_ Lot SizeQ &21 a ck-q4t. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. reuired) gpd Calculated design flow Design flow provided gPd Plan: Date_ Number of sheets J Revision Date Title Description of Soil (s) _ Soil Evaluator Form No. Name of Soil Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 8WL co-) g T - c��� � ��✓ �'Y The unders' d agrees to install the above described•Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ag� to plc on until a Certificate of Compliance has been issued by the Board of Health. Signed V M e Date -r No.� FEE COMMONWEALTH Of M, SSACHUSETTS Board of Health, A)QVV � , MA. �✓ �u ?/ CERTIFICATE Of COMPLIANCE Description of Work:. ❑ Individual Component(s) P-do' mplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( ) by: (� i c hpaPbeen installed m accordance with dated � pro �/n�of .310App oved Design Flow and t approved design plans/as-built. plans..relating to application No i ( d) Installer ,�//�� , Designer: tr f �%. .- `d iZ-VI 1%`1t:'Inspector: Date: The issuance of this permit shall not be construed as a guar tee tht the system will function as designed. No. CO's MONWEALT14 OF MASSAC14USETTS Board of Health, 01 MA. DISPOSAL, SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade q, -r Abandon( ) an individual sewage disposal system at�/J.� �� �: as described in the application for Disposal System Construction Permit No., dated - Provided: Construction shall be completed within t rs of the date of this per it. All local conditions must be met. Form ate Rev. 5/96 A.M. Sulkkiin Co. Boston, MA ate / / c'25—Board of Health C1u �i7