HomeMy WebLinkAboutApp-Permit-ComplianceNo.
FEE
COMMONWEALTH TH Off' MASSAC14TTS
YARMOUTH HEALTH DE
Board of Health 140 ROUTE 2-e , MA.
APPLICATION FOP DISPfA'tAT '1 (MRUCTION PERMIT
Application for a Permit to Construct( ) Repair(Vr_-U1,pgrade() Abandon() - ❑ Complete System ❑ Individual Components
Location &Z
v [ N(_W .t) (W.
Owner's Name Ir✓A• o a 0,L-c,—
Map/Parcel#
Address codi/v(,-W�
Lot#
Telephone# -37(
Installer's Name�
Designer's Name
Address
Address
Telephone#2 A �l��
Telephone#
Type of Building /, N(r�B -tv Lot Size
Dwelling - Nq? of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS 1412ig. EC D 0)(
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
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 system in operation until a Certificate` off Compliance has been issued by the Board of Health.
Sine
g k#5o-"- cO , Date
Inspections
No.0 (�� FEE �L
COMMONWEALTH OF MASSAC14USETTS
Board of Health, VAi2MG✓ MA. / ) 014
CERTIFICATE Of COMPLIANCE
Description of Work: UrIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
by: Robe/k 6. OUr CO. ZrvC..
at (' % �'o1llN(,WL9j � �Gf �/GcfW7v�i�. pU✓% nn/1-
has been installedin accordance with the rovisifons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 4 dated _ G `(� Approved Design Flow (gpd)
Installer OLi�- L v,.- ev, -I-r/c•
Designer: Inspector• L.G/ Date:
The issuance of this permit shall not be construed as aarantee at the system will function as designed.
No. V i✓ (/ l FEE 6 K
COMMONWEALT14 Of MASSAC/14USETTS
Board o.f Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (d) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at C,)/(, NG as described in the application for
Disposal System Construction Permit No. 0 dated �-
Provided: Construction shall be completed within 4& �s of the date of this permt. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 4 /� O S Board of Health C �