HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT. ��RZ FEE Ub
No. ��'"1146 ROUTE 28 r a
60H - clz sc4f Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location R Eml J 4$5 L4'/J�
Owner's Name --re*/J � �� d ��Q Cl k�
Map/Parcel# f 5 l Yoz
Address 3a G -m brrS5~-/ l.-10 Yom Ddb a a (p
Lot# 50
Telephone# 5 6g - 361 - --Z ,�-7 d
/Vo�n-9- COns+V--C-+ col,
Insta�eer' Name ,rd- ��C�4J� d c0 r P.
> .t.
Designer's Name T M D 12�. j%�
Address3a 5,1 (,A qNN L,^j P 0-Geya-3so j3f-JUS
Address 9 a. � 6x 1773 13r•-ews�. Aa. oab
Telephone# 5-o"g. ,� _'� 7 3
Telephone# ,5 0 - g - b 6 p
Type of Building 4_
Dwelling - No. of Bedroom
Other - Type of Building _
\�� l r 4-- Y%i 6 -
No. of persons
Lot
a15 (00 sq. ft.
to Garbage grinder( )
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) �0 gpd Calculated design flow Y s Design flow provided D gpd
Plan: Date O -7 52,611 Number of sheets I Revision Date
Title S 1 ;-e, -1 -P—uj 1 ,4, -D15 EPOS X1-1 S)( 'S+e-tr) D`Q ,S 112-21
Description of Soil (s) _
Soil Evaluator Form No.
el
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS D — dd )c - "- LgN-r- 4 t NG
The undersigned a es to install tbfi above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n t to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �" s/ 6
Is -
Inspections
(�7 f,4 ,z < <� /i 1( Gid
No. `� 1! J c 1 `t E? P (' 4 EE 0 .-
RALTH OF MASSACIaMMTT
CA* 9 9
Board of Health, y8jf% tit OJ 111- MA. ..M-
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradeAbandoned ( )
by: N0 tT7-tV- 5-F C0A)STjZ U C -i 0/J
5hasat kE M fl� IN, SS `1 L-A r•i i57-
has
been installed in accordance with the pr -s- ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 19. - o-l+C) E, dated 1 Approved Design Flow ��S..--(gpd)
Installer
Designer;, ill' er-1 ,.f ",' N5 5 OCA Inspector: � Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
c
No. (quo-DC-19-0gq—) %VC?(�TiiS CoA) 3T)?- FEE 6-5, 6 O
n 379
COMMONWEALTH OF MASSACHUSETTS <7
Board of Health, Y AV -M0 J j + , MA. � ' � � T
DISPOSAL SYSTEM CONSTRUCTION PERMIT
to ac i
Permission is hereby granted to; Construct( ) Repair( ) Upgradep<"Abandon( ) an individual sewage dis iosal system
at , -� 2 E ►til
Disposal System Construction Permit No. , dated
as described in the application for
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 Board of Health v F
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