HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSA, CITUSETTS
YARMOUTH HEALTH DEPS
Board ofl3ealthl1��R81-1:�__._
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APPLICATION FOR D1S1 9AyM"Ri"' MTfRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) pgrade AbandonO - Complete System ❑ Individual Components
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Type of Building r" Y.
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Design Plow (min. required) Z
Plan: Date _ J-- / 7'✓ v !
Title
Description of Soil (s) _
Soil Evaluator Form No
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Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS ORALTERATIONS
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No. of persons
Lot Sire sq. Ft.
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Showers ( ), Cafeteria ( )
Design Row provided 3__ gpd
Revision Date
Date of Evaluation 'jr'- 3' O
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 systc in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 2°
'" Date 6- 7,0 - /
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Inspections
No.FEE Wit/ t/ G✓
0011/nVIONWEALl'II OF MASSACHUSETTS`
Board ofTkahh, 2 / , MA.
CE1,T1rIr_/ATEE o0vI1�LIl1I�TCL
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Description of Work. ❑ Individual Component(s) Ira Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.'), Upgraded ( ), Abandoned ( )
by: ,✓G% '/,/ o 17g.f of � o f `i
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has been installed in actor dance with the provisions of 310 CMR 15.00 (Title 5) and thea coved design plans/as-buds plans relanng to
application No. ,r % - (�%. dated _ < Approved Design Flow (gpd)
Inualler /2 9 /z- F
Designer. /lata% „ter .r'Date: f
t Inspector:_
The issuance of this permit shall not b6/construed as a. guarantee that the system will. function as designed.
No.
4-20MN![ON IALTH OF MASSACHUSETTS
Board o/ 1ealth,�("✓� ,MA.
D1SPOS1L SYSTEM CONSTRUCTION 1?E11MIT
FEE /' /
Permission is liereby granted to; Construct( ) Repair( ) Upgrade(/') Abandon( ) an individual sewage disposal system
at 'ti °Z %fa 1`r%"'ar 7 X as described in the application for
Disposal System Construction Permit No. - 3(J-209, dated 6
Provided: Construction shall be completed within tluee.-ears of the date of this permit. All local conditions must be met.
Form 1266 aev. 5/96 A.M.9ulkln Co. Gaston, MA Dille (r' yo� / 0/Board of Health � -" �' /
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