HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. to _/6 s 1146 ROUTE 28 FEE
SO. YARMOUTH, MA 02664
COMMONWEALTII 'OV MASSACHUSETTS Id 7l
Board of Health, )vbl.
AISPLICATIION FOR DISPOSAL SYSTEM CONSTRUCTION PI!_RMIT
Applic:uion lora Permit to Consnvct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
C�rcA(\, &;r
Owner's Name
7
Nlap/Parcellf
[
Address
1
Lot# 'p
-?) 3 1 co
Telephone#
Installer's Narne
yvtt —cv-\ oe_ &--or
Designer's Name
Address i!
� S I
Address
- �<V�2&c 02 sy\a-
Telephone#
Telephone#
l�"7?j
Type ofBnilding 'Z'S.I,d.1e�n-�C.tA-� Lot Size
Dwelling, -No. of Bedrooms
Other -Type of Building No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures` / 7, /
Design Flow (mX31
in. required) 3 gpd Calculated design flow 4 7 Design flow provided JYcy gpd
Plan: Date S _ P� Crz) Number of sheets I Revision Date
Title
Desci
Soil I
Name of'Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS p� P k A 6c 5
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furdLu� eyreestb�tot•te. lxc+- rc ysYemin o�jn n until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 3-1-7-00
ell
- Inspections
No. mss" tD FEE .% '"
COMMONWE-A TII OF MASSACITUSETTS
6Ga` 17 7
Borard of Health, \ `a:'�' %�.h l 4- , MA.
CERTIEICAT,_ OF COMPLIANCE
Description of Work: rdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ); Upgraded (V<Abandoned ( )
by: f v k I _,r 9`} 1 1.._ --, c=: t v,_.
at
has been installed in acco}dance with the nrovisions of 310 CMR 15.00 (Title 5) incl th- ap roc d design plans/as-built plans relating to
application No. . /6`, dated Approved Design Flow " pcl)
Installer//> �
Designer: �, !:i°` f'r,�'d O oS^'l"e °`�Z....Inspector: W&,-1_4 Z Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. (.f -16 < p g%%���/ ` .m'°%r�y FEE �"i"" ' Ale
COMMONWEALTH OF MASSACITUSETTS
Board ofHealth., rL �.N�l( �-"� , MA.
DISPOSAL SYSTEM CIONSTRUCTIION PI1INIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(
Abandon( ) an individual sewage disposal system
at tor cc e ��^u (rV6 t✓.t c^ as described in the application for
Disposal System Construction Permit No. 67J16 , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
r� t`%
Form 1255 Bev. 5/9G A.M. Sulkin Co. Boston, MA Date/ _ / / 6� Board of Health/ ��A / ✓ ✓ F..✓/p%/-/' '"4. ..a"P .G+",. �"`