HomeMy WebLinkAboutApp-Permit-Compliance'YARMOUTH MEALTH DEPT.
7N°°: 1146 ROUTE 28 -
Board of Health, YAA4%AMA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMI1
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FEEQ I
Application for a Permit to Construct( ) Repair( ) Upgrade (tr)"'Abandon( ) - WIComplete System D Individual Components
Location'
Owner's Name
Map/Parcel# 39 2
Address GL
Lot# 2-
Telephone#
Installer's Name
Designer's Name
Address
Address ►A
Telephone# , OYAW
Telephone# a
Type of Building TlGtQ 1�A� Lot Size 2 D r, sq. ft.
Dwelling - No. of Bedrooms Garbage grinder W Q
Other - Type of Building No. ofersons Showers
p O,Cafeteria ( )
Other Fixtures
Design Flow (min. required) j / D gpd Calculated design flow a Design flow provided 3 Ve gpd
Plan: Date /Z w /gyp^ Q % Number of sheets Revision Date
Title
Description of Soils) O •- cr A % - �� ' kJ 39 ��'` 'C YVI 1�J1_�5A XJ4
Soil Evaluator Form No. Name of Soil Evaluator lei pLIp, MA4-mo j Date of Evaluation 11 - 21-01
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DESCRIPTION OF REPAIRS OR ALTERATIONS d%,14
`V 7,V ' X
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 place the toa in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed s.R i►, ) G , . ��; Date 6 " 3 O
4nspections
No. CL L� FEE
COMMONWEALTH Of MASSACHUSETTS
- - . Board of Health, Y4A1,LAjJt6, MA.
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CERTIFICATE Of COMPLIANCE
Description of Work: D Individual Component(s) complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (-), Repaired ( ), Upgraded ( ), Abandoned ( )
at lL,4 444 moi t, x:sr- , @ASS
has been installed in accordance with the provisions 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. --)- 3 7 dated Q . Approved Design Flow 3 'll O (gpd)
Installer
Designer: A�iA t S�a� Inspector• � 04* Date:
The issuance of this permit shall not be construed as a guarantee dat the system will function as designed.
No. C% �. f �- - - - FEE Oa
COMMONWEALT14 Of MASSAC14USETTS
Board of Health, YA /01L4 g (4_, MA.
EM CONSTRUCTION PERMIT
DISPOSAL SYST
Permission is herebygranted"to; Con§truct(j() Repair( ) Upgraded( ) Abandon( ) an individual sewage disposal system
at % y r �cLl�� a � 5 V4A,64�- aj$ as described in the application for
Disposal System Construction Permit No. �% -Z' J7 , dated U� .
Provided: Construction shall be completed within tl 4 6�ZUS
p -of the date of this. permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board O Board of Health