HomeMy WebLinkAboutApp-Permit-Compliance- _ YAHMOUTH HEALTH DEPT.
No.!� 1146 ROUTE 28 FEE -�o
SO. YARMOUTH MA 4 6
COMMONWEAL4 OMASSAC14USETTS Pj
Board of Health, C41yr MA.
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APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location a a IL
L_OG k (A_^
Ir..j d- Owner's Name i
Map/Parcel# log
,
L Address
Lot#
/3 Telephone#
Installer's Name
Designer's Name
Address J`h� v/'"L ^ -
Address
Telephone#
Telephone#
Type of Building I le -P PVj Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required) Ll L gpd Calculated design flow ! �0
Plan: Date I/11 f c I Number of sheets I
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Title
Description ofSoil (s) 5'2f -i' S- i.` L��`/
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S -e -e K J
The undersigned ayees install the above described Indi ' ual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nace a - - til a Certificate 1�7 �anceeen ' e by the Board of Health.
Signed ✓ Date
Inspections
'J
L is
No. FEE
COMMONWEALTH Of MASSACHUSETTS
M
Board of Health, /aJ 6 c 0 �'1 , MA. j `/ C
?S K
CERTIFICATE OF COMPLIANCE �
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: i -t o h y n 01,10 19) i ( 4 C c, e' i0 --e t-
at e9 r') Lc t, � t, --v, \�, 'c, r m t- n i r t
has been installed in accordance withvthe provis ons of 310 CMR 15.00 (Title 5) and
�the approved design plans/as-built plans relating to
application No. iC1 s, dated - % �! Approved Design Flow L (gpd)
Installer iI i t AGc 174 ( Cc digJ , Co
-
Designer. Lac ,,,, r <-C-1n P 17
n i � o, s ector: 11.e� + 6'1 Date: d4 9?
t 01 —
The issuance of this permit shall not be construed as a guarantee that the system function as designed.
No. -r� - -_ _- FEE
OMMONWEALTH OF MASSACHUSETTS
046 Board of Health, \ la d, 011 G &1 J v { , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction PerVnit No. dated 7
Provided: Construction shall be completed within three years of the date of this permit. Alflocallcco�nditions must be met. ;<
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA DateBoard of Health.G