HomeMy WebLinkAboutApp-Permit-Compliance., ,' I „ , � " YARMOUTH HEALTH DEPT,
Nn. 1148 ROUTE28 FEE
COT NTMPX 1 IMMSSACIIUSETTS
Board of Health, Md.
A PLI ATION EOR �'I! � DISPOSAL SYSTEM CONSTRUCTION P I$ 0 1 1999
HEALTH DEPT.
Application for a Permit to Construct( ) Rcpair(lO Upgrade( ) Abandon( - O Complete System O Individual-Co—niponenis ""'
Location(WC
Owner's Name I 7F
Map/Parcel# V J�
Address 10
I'ot# %7Z> p?.� �'
Telephone#
Installer's Name
Designer's Name
Address
f 6�
Address
Telephone# i
Telephone#
er Type of Building I (, r6dLot Size
llwvtlinv-Nn. of Rrrlrnnme
Other -Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
_ gpd Calculated design flow
Number of sheets
sq. ft.
Garbage grinder ( )
Showers ( ),Cafeteria( )
Design flow provided
Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees �t/to ecje ti e to n o eration until a Certificate o i as been issued b the Board of Health.
Signed �' (a ty_ A t� � Date f 1 71 y
No. (�q ;-/ /
COMMONWEALTH OF MASSACHUSETTS
Board ofHeallh, W ` A _:t1t -'
uj TIcm_ or COMPLIANCE
Description of Work: Individual Component(s) O Complete System '
The unders)FPed ljerelly certify that the Sewage Disposal System; Constructed ( ), Repaired , Upgraded ( )
YiJtf7'U(f / f
FEE_
i
by:F4.LOCi.,✓- �K_ ,W('
has been installed in accordance with the provisions Goff3310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �%�Y
`'i /, dated /� -/- . Approved Design Flow (gpd)
Installer
Designer: Inspector: 1. Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Boatel of Health, .� �' 1.�;f,�''�1 ti MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
at
BE
FEE
is herebygranted to; Construct( ) Repair(Upgrade( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No. ✓}� dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit, All local conditions must be met.
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Form 1255Rev. 5196 A.M. Sulkin Co. Boston, MA Date—��/Board of Health