HomeMy WebLinkAboutApp-Permit-Complianceo r --C,4 Or -
No. IVr/vj �L �U .. �r (J(��� FEE
70
�y'WMMONWEALTII OF MASSACHUSETTS
YARMOUTH HEALTH DEPT. �yn&)
Board of Health , MA.
APPLICATION FOP, DISP@9AVTMTW(MRUCTION PERMIT
Application for a Permit to Construct( Vj Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name C r}
Map/Parcel#-2
Address 13Z-7 e url- i
Lot# 2Telephone#
Installer's Name (j,()- Q44-3 CQ
Designer's Name
Address t 6..
Address F 0
Telephone# gAo— Z1aI
Telephone#
A4 P
20111
Type of Building L&) I,I !:n . , Lot Size 1 + sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder (�
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. eq ired) ?D ?2 0 gpd Calculated design flow -3 Design flow provided gpd
Plan: Date 07,n Number of sheets Revision Date
Title4. C R
Description of Soil(s) �l '
Soil Evaluator Form No. Name of Soil Evaluator 1� /a �� / r, Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
`The undersigned agrees to install the above described -Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
farther agrees to not to place the system in operation until a Certificate of Com fiance has been issued by the Board of Health.
eigned V �� Date a
I/
Inspections tL O l—
'4A c.!- k 50 — P �1 a� S" A- > cw /tom �.°� c1
�/ �' ' ti 7.r- 7iy %? .
No. � 5 41 f l ` �� 1r p� 5� C
COMMONWEALTH, Of MASSACHUSETTS
�r 5X01 371
Board of Health, j wr Y"Yl. /1 t T ► MA.
G/G
CERTIFICATE Of COMPLIANCE f 1`40-%t � �,1 � t. VL spec o
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby•certifythat the Sewage Disposal System; Constructed ( ), Repaired ( ),Upgraded ( ), Abandoned (
by: 117V &7sit_ dOk
/ \
has been,installed in accordance with the rovisions ok310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. 1014 p '��, dated � /6 G _.• Approved Design Flow (gpd)
Installer
Installer To" 1
Designer: Q2 Inspector:...� Dater
The issuance of thispermit shall not be construed as a guarantee that the system will function as designed.
4
FEE
COMMONWEALT Of, MASSACHUSETTS
Board of Health, `saJ"("�,1 MA.
DISPOSAL SYSTEM CONSTRUCTION-, PERMIT
Permission `is hereb granted to; Construct( t ,Repair( ) Upgrade ( ) Abandon,( ) an individual sewage disposal system
at 1 i 1 AJF, � 11 �i1 ' ` Zf' as described in the application for
Disposal System Construction Permit No. `. , dated f®4—
Provided: Construction shall be completed within.i of the date of this per • it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date."lt `Board of Health
e . n1 % •c l_,'3i / ..0 /E "� -�. e . ilii i!- .�._.. i 7..r�-,.. ". -�- .^r� � .r. i . i l—