HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE (54110
COMMONWEALT14 Of MASSACHUSETTS
YARMOUTH HEALTH QCOT
,board of Health,
APPLICATION FOP, DISPOA%,CWWCTI®N PERMIT
-;s
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() ❑ Complete System ❑ Individual Components
Location An
L
Owner's Name f Q
?vlap/Parcel# 3�
L
Address I1A A -a LAI tZ-1
Lot# 6 ale
�
Telephone#
Installer's Name
�/ l
Designer's Name
Address '? ( f �(
C CK/
Address S
Telephone#S�L
Telephone#
Type of Building A
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size b sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) , 3-170 gpd Calculated design flow Design flow provided J12L gpd
Plan: Date �" e '� �� Number of sheets Revision Date
Title
Description of Soil(s) IGF 1t, '
Soil Evaluator Form No. Name of Soil Evaluator 1: wlt--Sp?)�ate of Evaluation
DESCRIPTION OF REPAIRS ORTERATIONS 6 O / %� �(yIz' 115�GZ Ad /le /66TF�A .f
AO
<; -1 or L* mak. &( -�T "
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to noto pla the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date i L� "
Inspections
8 �--
No. '
COMMONWEALTH OF MASSACHUSETTS FEE
- N /' "`iBo r of Health, //9i1 GL J MA.
-CER
IFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersi ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded `( ), Abandoned ( )
by: A� ( 14 C ` r t
at i /vim a .1
has been installed in accordance with theprovis s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 6L 2-
`.Z _75- , dated 6 � . Approved Design Flow 37.L—(gpd)
Installer /P/_//L G r✓'i i
Designer: Glizf//? ,1=-GY(! ' Inspector: Date:
The issuance oof this permit shall not be construed as a guarantee that the system will function as designed.
No. V/ / l� L
COMMONWEALTH (MASSACHUSETTS
Board of Health, MA.
DISPOSAL S YSTCONSTRUCTI®N PERMIT
U
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon( ) an individual sewage disposal system
at 4 �F as described in the application for
Disposal System Construction Permit No. I 757, -dated
Provided: Construction shall be completed within tirr� the date of this i
//�`t. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date %� G� Board of Health r!l�Vf_�
,a A -d `)7 i / /%Gr//:a 7 f'"vi i / A "'07