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HomeMy WebLinkAboutApp-Permit-ComplianceNo.o)- -- I K FEE 7 WLT14 OF ETTS COMMON YARMOUTH HEALTH DEPT. Board of Health, 146 Ro i2 Q , MAT APPLICATIONFOP,DISP09A' ��IlI �.�?W(9 ftUCTION PERMIT Application for a Permit to Construct( ) Repair( grade() Abandon() - ❑ Complete System Vd dMdual Components Location 10 � Q_& Owner's Name Map/Parcel# $ (ZQ� Address 13 -% 6'.1'a" � rX Lot# Telephone# Installer's Name COQ C Designer's Name Address S~O Address Telephone# '7-7. ©O Telephonet, Type of Building QP_c-Lot Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons Other Fixtures sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design Flow (min. required) gpd Calculated design flow Design flow provided Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ oil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS s _ gpd The undersigned agrees to install bove described•Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr es to ace syst m in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections c _ No. ' P Q COMMONWEALTH �T��j j� MASSACHUSETTS �( (�(�(�T FEE. Board of Health; 1°fNo VAC MA. CERTIFICATE Of COMPLIANCE Q�G Description of Work: alndividual Component(s) ❑ Complete System S The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired Graded ( ), Abandoned ( ) by: R3 C�c�n at 10 { -y, PA 4A has been installed in accordwic,� with the provisions of 310 CMR 15.00 (Title 5) and th��proved design plans/as-built plans relating to application No. 40..� ^ ( dated Approved Design Flow (gpd) Installer �'� Cc..:,C Designer:. Inspector: Dater The issuance of this permit shallnot be construed as a guar tee that a system will function as designed. No. FEE C COMMONW~ BoardofHealth, �l`datt�rn©vtt'in MA. 1141t DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair (Upgrade ( ) Abandon( ) an individual sewage disposal system at 0 a2� "�` Q A v1-- as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed withi�ars Sf the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date S —� _d2 -Board of Health L4e Ss .ice.-G�c-►i'