HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH OF MASSACHUSETTS 7G1
YARMOUTH HEALTH DE"'
BoardofHeaIIh,4 4 rp-oto ndA. �-,f /'-�C4`'`�
APPLICATION FOR DISPO 1Y' �1 ���' ' �Si'1'UCTION PERNITT
Application for a Permit to Consu uct( ) Repair( ) Upgradevlbandon( ) - ❑ Complete Syste"Individual Components
Location d L
Owner's Name sc
Map/Pinel#
Address 3 So-
LotB
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Telephone# �5D—_3 4- oqw
Installer's Name m S
Designer's Name
Address .1 /*J� l
Address
`Telephone# C
Telephone#
Type of Building Re--::, / Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Plow (min. required) -----
'�� gpd Cakulatcd design flow Design flow provided � gpd
Plan: Date Number of sheets J Revision Date
Title
Description ofSoil (s) 1'IL( 7 L Or:rMV 5n—JA)D 72 MPnl r-1��fA,,,%r��P S?WD
Soil Evaluator Form No. Name of Soil Evaluator 4XM)Date of Evaluation 5ju
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DESCRIPTION OF REPAIRS OR ALTERATIONS �i—i3�� `- Z_r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree�(o not to place the syste in ,o�peratio///WntCertificate
of Compliance has been issued by the Board of Health.
Signed firma tZ Date oIo
Inspections
No. p) ,..rr ,. ,r" i !'i. r, ,`t.; i%.a
FEE,,
COMMONWIAITII OF MASSACHUSETTS
Board of Health, ,'.7 ) ) U I tp%i` MA.
CERTII,ICAT1. OF COMPLIANCE
Description of Work: Y/Ibddividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded
Abandoned ( )
at 'i � l'r tr't J' Ll t<'t'') i r'i n.l �".
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 e) :,, - C" dated -7�% Y'� 6. Approved Design Flow '"?° gpd)
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"Installer/r�'�1
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Designer: "'IJ'!�,( (-i Inspector: Jt' s r ✓d � 4 d r.al. Date:
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The issuance of this permit shall not be construed as a guarantee tat the system will function as designed.
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COMMIONWEALT-14 OF MASSACHUSETTS
Board if Health, 7 'p ILW01 i i i -t INCA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (1"dj`" Abandon( ) an individual
sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. /.! UF,r "} dated 1 Z 7(/6
Cn
Provided: Construction shall be completed within ehreeG. -{rears of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Bulkln Co. Boston, MA Date + / ("Board of Health
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