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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ©7 3/( � „ ,. FEE '/� /17�v,-L-,-, COMMONW-,EALT,II OF MASSACI4USII--TTS YARMOUTH HEALTH DEPT. 6e6;iGL�d Board of 14 MA. APPLICATION FOR D1?1)Y��XQVs1t�bNSTRUCTI N 1D,ER.MIT Application fora Permit to Consu'uct( ) Repair( ) Upgrade{ /`�Abanclon( ) - ❑ Complete System�dividual Components Location '7777 767, Owner's Name Map/Parcel# yo^. 1,.;;,6 Address O NJ f✓G�2 r- ,.,y �•j• vapy Lot# j�p Telephone#-��- Installer's Name/ 4,t„1_7- &11-, ^ Designer's Name p�eV Address thole 4i eAlevi(`'^' Address ,G - 40CIK 9,9af/ d-� .p x.v.�t`r/eGLi l✓oZ�•3% Teleplione# - 2. 0 $ 34, Telephone# Type of Building Dwelling -No. of Bedrooms Other -Type of Building _ Other Fixtures Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design Flow (min. required) %///l gpd Calculated design flow 6-67) Design flow provided 45ez gpd Plan: Date 9__11e9• ^GY6 Number of sheets O Revision Date Title Description of Soil (s) _ Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed• .✓ ,✓? (/r.t^ (11 Date Inspections lid/ Lid 'kre> l' b. d'fO a2s6,r-1f7) l Ca f4,P,u" ✓ G �'^ i57�ZJ+jm°�K�L%/y,r1rld�jc�i y -a- ' •215, '11 1 ) 6dLZ kkli> S dr k ,f br? U C•' .t ••dCt ) . dli� ^z � kill n • ! . Y /i-/3-67 ajaa CO3? �% tri Gnncc fT Itpe, o No. cu COMMONWEAL -1 OF MASSACIIUSLTTS� �'� , �ri��� � ) Board ofHeallh, iVr"/,vtUG/—/ ,NIA. 0" CERTIFICATE SOF COMPLIANCE Description of Work: Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed (q, Repaired ( ), Upgraded ( ), Abandoned ( ) by: at 'cF':"6 /�✓ 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 /N}o.��P 0 - '✓,^�/6 , dated /`/_ ! � C,1 —7Approved Design Flow a (gpd) Installer d�°'+"d^T 0 . _ (%v/' Cc+- ,774-c- 171 -? r: Designer daf/'ev%f .^ -t°'ff!' /`l'_ -s Inspector: f ... ! . Gr_ (' Date: r g The issuance of this permit shall not be construed as a guarantee dist the system will function as designed. No. %, A.. -a', FEE . 00 COMMONWEALTH OF MASSACHUSETTS Board ofHeallh, ; 's''° ° 1017/ JWA. 1 1DISPOSAI. SYSTEM CONSTRUCTION PERMIT Permissionryishere/bygranted to; Cnstruct( ) Repair(L4 Upgrade( ) Abandon()anindividualsewage disposal system at c Ms °l as described in the application for Disposal System Construction Permit No. 01 - _�16, dated (® W, a Provided: Construction shall be completed within-tlir e•years-of the date of this peytrait. All local condition,§,must be met. F= 1111 Pev. 5/9fi A M Sultrin Ca. Boslan, Mp-�� Date� Board of Health � (/ V f / �/rl ,'� ,F ! �,,..-q' .✓^ tl / ( / b' ///^.%4r .r�l� / 4r�