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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE YARMOUTH HEALTH DEPT. Board of Health, 1146 ROOTE 28 , MA. -APPLICATION FOP, DISP09AM"M,MT9MUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location O Owner's Name Map/Parcel# , Address PAN, -4C-_1 Lot# © 0!__P Telephone# _,�*&6 Installer's Name Designer's Name ` t4, Address `� ; ��% Address -7 W tea -(-S U IGJe! Telephone# — Ciro ZN Telephone# ,7 _ Type of Building f:�!$fJy��`-'��� Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required)) ��� gpd Calculated design flow ctv3 Design flow provided �3 gpd Plan: Date 6— 5—OZ2 Number of sheets Revision Date Title (,i` r nt, ooeAk Description of Soil (s) _ Soil Evaluator Form No, Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS � v to \ 0A r--, It I Date of Evaluation The undersigned agrees to inst 'bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur s Signed c not top t in operatio rtificate of Compliance has been issued by the Board of Health. Date -u ,/,ki No. � / C®MMO V'V' EALT1jt O MASSACHUSETTS Board of Health," MA. CERTIFICAW OF COMPLIANCE X..,f Description of Work: 1*Individual Component(s) ❑ Complete System 7 The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded if by: at FEE�� has been installed in accordanc with the provisions of 310 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to application No. ^�Z dated F3 " / S' Approved Design Flow Pd) Installer Designer: Inspector: ate: The issuance of this permit shall not be construed as.a guar te'e�that th system will function as designed. No. //� FEE -1ST COMMONWEALTH OF MASSACHUSETTS Board of Health, _7NMA. U DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to;. Construct( ) Repair( ) Upgrade( 6.,�andon ( ) an individual sewage disposal system at a ,^\ik as described in the application for Disposal System Construction Permit No. . �� dated r �- Provided: Construction shall be completed ��^within ^three years of the date of this permit. All local conditions must,4e met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date V _�J oard of Health