HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.1146 ROUTE 28 %� _
No. =� SO. YARMOUTH, MA 02664 FEE `�
W`PO-��COMMONWEALTR OF MASSACHUSETTS
1
Board of Health, / , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location Lio e
6't-
Owner's Name
( l 1� 1 CCD
Map/Parcel# a S --
aq 0
Address 3
4,4 t$cm Pj. nA
Lot# a y Q
Telephone#S
ljFf 10If- a
Installer's Name
Designer's Name
Address
350 Main Str
Address
Telephone# W.
Yarmouth, MA 02673
Telephone#
3 % ( 0
Type of Building 1<4ff S • 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) 3 3 d gpd Calculated design flow Design flow provided gPd
Plan: Date i 1 0)o ' 1 Number of sheets Revision Date %V
Title k1 / l'_F_
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS �'J-G P RMAJ
Date of Evaluation
The undersigned agrees to install the above described, Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tot joteCAAt,
0ce the system in operation until a Certificate o�yfrCompliaance has been issued by the Board of Health.
Signedy), Date / F—
inspections
No. � � FEE 5
COMMONWEALTH j/Of MASSAC14US ETTS
Board of Health, A-UtH MA. x ; 3,
CERWICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) r3Complete System'j
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Ir, -Upgraded ( ), Abandoned ( )
by: ti G u
at ��U C &r J-71 S,C&-I.
has been installed 'n accordance with therovisions of 3310 CMR 15.00 (Title 5) and th a proved design plans/as-built plans relating to
application No. 4 ?V, dated 2S '•'k17- 9d . Approved Design Flow '�7(gpd)
Installer
Designer: Inspector:��L�f 6ti�'1 �� Dater _ e% ,ci[�
The issuance of this permit shall not be construed as a guarLee that the system will function as designed.
t ,
No. % 3 FEE Y-6
C®MMONWEALT14 OF MASSACHUSETTS �G �� �-745
Board
oa d of I . YCr.9v� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at�f1 C -P�� ST • cc�� as described in the application for
Disposal System Construction Permit No. !, dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 17— d" Board of Health '