HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0--)k3 -) 3 J-+� r �I�n ` /O 1 / & FEE t;� ,e (CJ
41M® LTH OF MASSACHUSETTS
YARMOUTH HEALTH DEP�
T Board of Heal a� 4614MTE 28> j Aa -e.
APPLICATION
FOR DISnW49T 'lm][fi(" RUCTIO1V PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade,f<Abandon( - ❑ Complete System )'Individual Components
Location (p ' f'h i - S!- f -e co-!
Owner's Name /2. 1-,+r�- ML
Map/Parcel# �. % .. C3SQ
Address (�h S' �` f C
Lot#
Telephone#
Installer's Name�� a /aT�' �� 5�-
Designer's Name
Address 6L3 12,1 , fir- ,.yP ACf
Address I 6d146- - Cl Qe j 7P-5
Telephone# Slaxt 3 6(2-
Telephone# Fff ^ 36,/ Sey.l�ti^v
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 'Z �� gI� G'/ -3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) _ gpd Calculated design flow Design flow provided �7pd
Plan: Date Number of sheets Revision Date
Title
Description of Soils) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned ees o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees/ of t` ace e o until a Certificate of Compliance has bee. ' sued by the Board of Health.
Signed F DateZZ
• Inspections 1-.2
4
V
No. � / �� � FEE
COMMONWFALT14®F MASSACHUSETTS
Board of Health, (la/ 4-1 C tet. 1,-t"% MA.
CERTIFIC TE OF C®MPLIANC X � � � �
Description of Work: ,,O' udividual Component(s) ❑ Complete System
F.
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: f Z �l cS G3�a � erg de i � S 11 i / C-- ,06 IT
at 1 ' S J- -f' c r� ✓� \
has been installed in accordance with the pro sion of 310 CMR 15.00 (T e 5) and the approved design plans/as-built plans relating to
application No.dated I Z Approved Design Flow �.3 gpd
Installer � I 1 'S Q � 04 /1 ,
Designer: -,c- Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No./ '. Q -3 % _ FEE
COMMONWEALTH Of MASSACHUSETTS �� � � 771 �
Board of Health, / i'Yl Gam- , MA.
DISPOSAL S 1ST NSTR CTIOly PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at j & T� 1, S'} i -( C , �- C l �, V-- � rt'` C 41 rdi ./5 G" r'J- as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within %r—sof the date of this permit. All local conditions must be met.
,,�7 e-, ,
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date/—> �" t1 %card of Health