HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT. Ota
No. ?9- 1146 ROUTE 28 FEE
SO. YARMOUTH, MA 02684
Q COMMONWEALTH Of MASS CHUSETTS 11,717
Board of Health, = , MA.
APPLICATION FOP, DISPAL SYSTEM CONSTRUCTION PERMIT
,Application for a Permit to Construct( ) Repair( ) Upgrade(�bandonO - frComplete System U Individual Components
Location 6
Owner's Name
Map/Parcel#�► �C, �-
3 Address l
Lot#
ir Telephone#
Installer's Name
Designer's Name
Address Ij
Address '
Telephone#,
Telephone# 3� .• 3
Type of Building 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 5"�r gpd Calculated design flow -q3d Design flow provided gpd
Plan: Date 013 9 Number of sheets J Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Tl a undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
,further agr e,5-ton��ot to place the to in oper, tion until a Certificate of Compliance has been issued by the Board of Health.
Signed �G.'JIM� Date D
Inspections
NO.ONWE
�a
ueL,_ Y
Board of Health
�:', z ,
CEPTIFIC
Description of Work: U Individual Component(s) 011c"
The undersigned hereby ce that the Sewage Disposal S
by:
has been installed in
application No. I?W
Installer,
Designer: _
The issuance of this I
yra»4�
the rove 'on 10 CMR 15.00 (Title 5)and the prove
J Approved Design Flow-{gp
Inspector:
dc�
is FEE
-AV/11
mc&/ l
a �g —
�to
shall not be construed as a guarantee that the system will function as designed.
No.
Board of Health, MA.
DISPOSAL SYST CONSTRUCTION PERMIT
Permission is hi
at G 6
FEE ,S`�
f
ted toy Construct( Repair( ) Upgrade Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No 'y! , datedi0
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date''Q_ Board of Health