HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. �0 �Z 1146 ROUTE 28 FEE
80. YARMOUTH, MA 02664
d&UMMONWEALTH Of MASSACHUSETTS
Board of Health, &Zmc fJzlj�- MA. ice,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (/<Abandon(/ J/Complete System ❑ Individual Components
i
Location 16
Owner's Name &n4- %1 6400'44' C
Map/Parcel#
- J 13
Address
Lot#
Telephone# 766 - 6 �2—
Installer's Name
el e-1 .
Designer's Name , J. CA Jr 1IAv
Address
��� Y+
Address 50-X ".
Telephone#
j%
Telephone# % 7S Q0
Type of Building Jbwel ` Lot Size
Dwelling - No. of Bedrooms Z
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required) ., 2
J 36 gpd Calculated design flow 3 sd
Plan: Date a owls 'f. 1Qq A Number of sheets i
Title 1T i; N/4.,r�r�rauAvr.Q U, �it� r.4 c � 3
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
sq. ft.
Garbage grinder (Ip 0
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
16 UwJ,-&. Aew-.
3 JrG� gpd
Date of Evaluation Sh25
The undersigned agrees to install the above described4ndividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t ie tem in o eratio til a Certificate of Co pli a has been issued by the Board of Health.
-vSigned Date ZB
A
,inspections
611
No. C®Ml°,ILO WEA1 TJ7t,-Of MASSAC141JSETTS FEE
`
Board of Health, MA. j Gk
�A-rr��� � �7� ,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ;Momplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned f,%f
by: X'9 y- 7�Oza
at / n r.� t�l/rt..r
has been installed in accordance with the provisions o?310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. - dated 7' . Approved Design Flow_(gpd)
Installer
Designer: Inspector:
The issuance of this permit shall not be construed as a guar tee that th tem will function as designed.
No. D"r -IR 9 13 66 11%a e FEE _-.moi -
COMMONWEALTH Of MASSAC14USETTS
Board ofHealth, TS, MA.
SYSTEMDISPOSAL CONSTRUCTION
T
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon(,e<an individual sewage disposal system
at 16 L/y f� �- � l�r^aq QJ, Yf-) /'/'"lMlkj-i l�1 , as described in the application for
Disposal System Construction Permit No. ' dated - ?�
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 7 — — 7 Board of Health /�/