HomeMy WebLinkAboutApp-Permit-Compliance��/�� YARMOUTH HEALTH DEPT.
Ni . =r 1146 ROUTE 28 FeE/`/v
YARMOUTH, MA 02664
COMMOTWEALTII OF MASSACHUSETTS
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System WIndividual Components
Location
Owner's Name 0,,�,04 6L [-
Map/Parcel#
Address d, V F,,Q Al
Lot#
rift)%
Telephone#
Installer's Name
lvco
Designer's Name
Address
N 5 . V
Address
Telephone#
9 .9,5- - pJ U
Telephone#
Type of'Building%/a u S £ Lot Sire sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -;�A--4c-
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree. system to not to place the sysm ' r operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r79 �-� ,- Date
(51
No.qF —116 FEE� '✓
CIOMMONWEALTII OF MASSACHUSETTS
Board ofTleallh., (aA cy}///T , NIA.
CERTIFIICATE OF CIOI� PLI ; yCE
Description of Work: 0l Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded ( ), Abandoned ( )
by: 1 V'R Nyx/C 0 �
at 97 � ,Z /('/fi,�' LA- A, - Y/ 414
has been installedin ccordm//ue with the provisions of g10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _.I!J dated :4 / �� . Approved Design Flow (gpd)
Installer A 21148 t?69A/C 0
Designer: "' Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. / �J ..'.. �� FCC A w `�•
COMMONWEALTI-I OF MASSACHUSETTS
Bocrazl of Heallla,✓ NIA.
DISPOSAL SYST91NI CONSTRUCTION PERMIT
Permission isherebygrantedto; Construct( ) Repair(,) Upgrade( ) Abandon( )an individual sewage disposal system
at � 3, �� t t �F/f >L L.e % / as described in the application for
Disposal System Construction Permit No. �`�%� , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditioList be met.
Form 1255 Bev n 5/98 A.M. SvIkin Go. Boston, MA Date _ / board of Health h, 6P,.�..... G,'f ' ff ll/
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