HomeMy WebLinkAboutApp-Permit-ComplianceNo. le -37
G✓� / �J C G 1 r9 3 O S �� G `FEE
C®MMON LTH OF MASSACHUSETTS
f7J OGt y J Board ofxealth, YARMOUTH HEALTH DSK.
APPLICATION FOR DISPOdd M, WI&RUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradeel-Abandon ( ) - ,9 Complete System ❑ Individual Components
Location
J 14.1 1/.I " IN.�
Owner's Name
Map/Parcel
/� - 2Z- ��-
Address/j7✓
,"
Lot# -
Telephone#
Installer's Name Z is/Go5 , w;v j.{-,
Designer's Name
Address
Z S L2/L/ ",�./N �Ll
Address /4/,/
Telephone#
lj �-. _ ��—�,Z
Telephone# 51�Ft7_
Type of Building.5/ / Lot Size G S tJ� sq. ft.
Dwelling - No. of Bedroo lt- 1 - `7`' Garbage grinder WU
Other -Type of Building No. of persons ;I- Showers( ),Cafeteria ( )
i
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided �` gpd
Plan: Date Number qr�sheets 3 � Revision Date —/9—/0
Title
Description ofSoil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil
,,D,,ate of Evalu on/ /✓ Z%'"'may `�
v�'� //!'? vitt✓ Yi✓/,t;,)
The undersigned a ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees oto plac the s e n operation until a Certificate of Compliance has been issued by the Board of Health.
Signed z7y Date 2�_ ,/o -'-ACS
Inspections
�' 7 FEE r ~• e%
No. COMMONWEALTH ®ESSACHUSETTS
Board ofHealth, a _14eNo�y-,IIVZ4 . NIA.
CERTIFICATE SDE COMPLIANCE cy; C
Description of Work: ❑ Individual Component(s) _-O-Complete System ,J
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.('j, Abandoned ( )
by; e, s
at
has been installed in accordance with the provisions of 310 CN,{R 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ' '% 7 , dated 2 -/f/.i . Approved Design Flow (gpd)
Installer ee/%J �' !.z'!N•
Designer: Inspector: I!`a "'� Date:
m
The issuance of this permit shall not be construed as a guarantee that. the system will function as designed.
No.
COMMONWEALTH, OF M, ASSACRUSETIS
Board ojFlcaltla, �, i `i MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
pFEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,(;-)" Abandon( ) an individual sewage disposal system
at �? / 177 /s1 N/ J (/ ,/^ r as described in the application for
Disposal System Construction Permit No /c% ��� , dat6d 2
Q_An ed 5Provided: Construction shall be completed within_tl�ewyears of the date of this,permit. All local conditions Hurst be met.
�� Board of Health 9� r
Form 1255 Rev. 5/96 A.M.Sultrin/Co. Chetle/5laxn,MA Date "`'
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