HomeMy WebLinkAboutApp-Permit-Complianceq YARMOUTH HEALTH DEPT.
N r us / 1146 ROUTE 28 , r FEE
COMM "Y'/, 6MASSACIIUSETTS ,. / c f'„s
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( "f Repair( ) Upgrade( ) Abandon( ) - M'I omplete System ❑ Individual Components
Location (2..
Type
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Owner's Name
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Map/Parcel#
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Address dJ
tAd
Lot# '> 7
Telephone#
r
Installer's Name
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Designer's Name �Jf'rd� ���faJ(y/.✓G.C2/
Address
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Address
Telephone#
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Telephone#
Z
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Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
No. of persons
Loc Size �sq. ft.
Garbage grinder ('�v
Showers ( ), Cafeteria ( )
Design Plow (min. required) ! (a gpd Calculated design flow Design flow provided
Plan: Date l�'S�'r 21/ Zr�J Number of sheets t Revision Date
Title
Desci
Soil I
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agree t install the abov describe ndividual Sewage Dispos I System in accordance with the provisions of TITLE 5 and
further agrees t lgot- E[ Ice the system operatio mtil a Certificate of Co lianc as been issued by the Board of Health.
Signed s / Date !/tqeq
,
No.
COQ' MONWLALTI4 OF MASSACHUSETTS
Board of Health, XV— ✓6//! MA.
CERTIFICATE OF COMPLIANCE
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Description of Work: O Individual Component(s) O'Camplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (,<Zepaired ( ), Upgraded ( ), Abandoned ( )
at
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. - f dated f2 c'^/S ` . Approved Design Flow :14 (gpd)
Installer 41//_A/A/' �Id
Designer: CGU( 3'-":S 4f`7C .s'IVF/s!P Inspector 494�* r C»�" ",?.'1'..d'' Date: •^^r' . G' U f
r`
The issuance of this permit shall not be construed as a guarantee thatt� a syssterm'will function as designed. -
No. /arJ - 2 &/L /1//1,/ C v ' /' FEE / �f
COMMONWEALTH OF. MASSACHUSETTS
Board of Health, Vzfs,' ./.1z°r5"7/✓� , MA.
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DISPOSAL SYSTE-M CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(,)-` Repair( ) Upgrade( ) Abandon(, ) an individual sewage disposal system
at ZIIA- 1i�= as described in the application for
Disposal System Construction Permit No. dated /-) ^�
Provided: Construction shall be completed within thrr"ear-s of the date of this permit. All local conditions must lie met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date L -Board. Of Health r/