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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ` a `—`y _ FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, YARMOUTH HEALTH DRAT. 1146 RU TE 28 APPLICATION FOR DISPO9AL'V I , 09W&UCTION PERMIT Application for a Permit to Construct( ) Repair(^pgrade( ) Abandon( ) - Q Complete System ❑ Individual Components Location 71-- Owner's Name k Map/Parcel# 02iaAddress Z 'F i , 4 I o vt -t` Lot# Telephone# Installer's Name �.� Designer's Name,?tz, Address ,;S-0+^ S K'2lM�,� Address 12 d Telephone# $_ Telephone# Type of Building 'XA.`t )A -Qt -1 Jiqf Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. Plan: Date I I Title��Mr'c h Description of Soil(s) _ "Soil Evaluator Form No. q )/ O gpd Calculated design flow Design flow 09 Number of sheets 2.l Revision Date _ 0 Name of Soil Evaluator OF REPAIRS OR ALTERATIONS 17 Date of Evaluation gpd The undersigned agrees to ins! 91 the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a e s to not to lac s tem in operation until a Certcale of omp fiance has been issued by the Board of Health. Signed r -ti — Date I I 1 b 8% Inspe ns No. ✓ �...A7 .a: a U C. ;f FEE COMMONWEALTH OF SSAC14VSftTS 2, s ; � ,� r� r, Board of Health,2ir �., �"Ir.MA. CERTIFICATE IDE COMPLIANCE Description of Work: D Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,) Upgraded ( ), Abandoned ( ) by: T, I c 1 at 2 i) n l' z �, R has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 0 of -2 i:, dated 1). ` i'- 09 . Approved Design Flow~'" .-a� U (gpd) Installer i �. ei A r 5 v'I Designer: Inspector: t Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. t l C©MMONWEALTIT OF MASSACHUSETTS Board of Health, �f/,/k? v: , — X1:4 , MA. DISPOSAL SYSTiM CONSTRUCTION PERMIT IT -f FEE Permission is herebygranted to; Construct( ) Repair( CKUpgrade( ) Abandon( ) an individual sewage disposal system at L `t( + I, C- C, `L f r.: / c-- as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed withintl�e date of this permit. All local conditions must be met. Form 1255 Rev. 5196 A.M. Sulkin Co. ChadeAoen, kN Date/- G /Board of Health / f Oa,d"_'<^.l Ik �CA'c:,uy ,.I/ /�-'=� :�'1 G^�,,.<:--r" ..-s�v 1', �-✓`cJ`r`.% � vK.. +..-?�� /�t�� L.�%✓�''�`�''s'!7