HomeMy WebLinkAboutApp-Permit-ComplianceNo. 04.
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ole i-6 COMMONWEALTH OF MASSAC14USETTS
YARMOUTH .HEALTHDF'T.
Board of Health, 1146 REWE 28
. Go i- k?f c S�?e5 I
l PLICATION FOR DISPOSM 9JCTION PERMIT
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Application for a Permit to Construct() Repair( ) Upgrade( P Abandon( ) - 4Complete System ❑ Individual Components
Location q/
0� �/e
Owner's Name l2Y,10
Map/Parcel# 1419PI15
Address i—
Lot#
Telephone# jo� - 3a ,
Installer's Name
/-1 60W flm� Nu
Designer's Name �S[=/\ &16:.
Address 3 '
OM RD,
Addressa� RJE IV
Telephone#
_16VAks
Telepho�'n1 e#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. re uired
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
of persons Showers ( ),
gpd Calculated design flow Design flow provided 6W -ft gpd
Number of sheets / Revision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS SM 846�A_l
The undersigned agrees to install theabove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further lace em in operation until a Certificate, o i has been issued by the Board of Health.
Signed �e l(JnI SII
Inspections '7-'I -t-f &zA dK_
s
No. COMMONWEALTH Of MASSAC14USLTTS FEE S, �
Board of Health, O , MA. p
CERTIFICATE Of COMPLIANCE
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Description of Work: ❑ Individual Component(s) 2(Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: r4 fI IV I rytl
z
at 16 WFLE
has been installed in ccordance with the rovisions o 310 CMR 15.00 (Title 5) and the p r ved design plans/as-built plans relating to
application No. dated -.� . Approved Design Flow pd)
Installer px �� 1- �" f1_a �C'7� S i
Designer: L.JV C9* • Inspector:_s� 11C.f NG///`�""'" Date:
The issuance of this permit shall not be construed as a guarantee that the system will Wmction as designed.
No. _o4
COMMONWEALTH Of �9y[ASSACHUS ETTS
Board of Health, If'fe (�� i f7 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission
�i-s--hereby granted to; Construct( ) Repair( ) Upgrade,V) Abandon( ) an individual sewage disposal system
at tl �: a � 20d /� • as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within tlrreyew oY the date of this permit.l local c/oon`t
d/itionsmust be met.
IKL
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
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