HomeMy WebLinkAboutApp-Permit-ComplianceNo. �r° FEE��OV
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Board of Health, YARMOUTH HEALTH DST.
1146 ROUTE 28
2— APPLICATION FOR D1SPO5AJY~VMAWX*&UCTION PERMIT
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`Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location 3/ VkeM le
Owner's Name
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Map/Parcel#
Address S
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Lot#
Telephone#
Installer's Name j 1
Designer's Name
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Address 1-7-7 �`� ` f�� �� �,i y
Address �I�
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Telephone# 31".r6 O l 7i
Telephone#
7 6 (�
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building
Other Fixtures
Design Flow (min. required) G
Plan: Date X'- 7 - O Z
Title
Description of Soil (s) _
Soil Evaluator Form No.
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers( ), Cafeteria ( )
gpd Calculated design flow 3 3 6 Design flow provided ✓7 yf gpd
Number of sheets / Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
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Name of Soil Evaluator
Date of Evaluation 2" Z % v
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 syst in operation until a Certificate of Compliance has been issued by the Board of Health.
SignedZv� Date /0- 5- 0-v
N
Inspections
No. G t.( at/FEE �Q .
COMMONWEALTH OF MASSACNUSETTS,
Board of Health, ] A-44A0C -P+ MA•
CERTIFICATE OF COMPLIANCE
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Description of Work: ❑ Individual Component(s) 'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (a;rRepaired ( ), Upgraded ( ), Abandoned ( )
by:
at 6 Ir
has been installed in accordar ce with the rovisions of j0 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. 62 " ••dated' Q - - O 3� pproved Design Flow (gpd)
Installer f 69 � 0 �,
Designer: e,, wdt�'1/c ( Inspector: Date:
The issuance of this permit shall not be construed as a! u tee thathe system will function as designed.
FEE '�(Jy .06
COMMONWEALTH. OF MASSACHUSETTS
Board of Health, "Le OU -141 MA
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; onstruct( V, Repair( } Upgrade( ) Abandon( ) an individual sewage disposal system
at .�/ L jas described in the application for
Disposal System Construction Permit No. a_7'7 4, -dated
Provided: Construction shall be completed within-tf�'rs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date AP 3 V2 --Board of Health
R l' E/ --ter!'%r� �' Z7 / / %ll___> 11.4.1411?