HomeMy WebLinkAboutApp-Permit-ComplianceNo. 10 ?� O� i3c.. v'c G..n-
C� FEE
COMMONWEALTH OF MASSACHUSETTS o"-t-� �aaTN
YARMOUTH HEALTH DEPT.
Board of Health, 1146 ROUTE 28
APPLICATION E®I2 DISPOMM, Mr UCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - I] Complete System ❑ Individual Components
Location 7 7
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Owner's Name ✓Y , r ,
Map/Parcel#
Address
Lot# Z
Telephone#
Installer's Name
Ike )?'.re
Designer's Name '
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Address �'!�
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✓ 11Writ In
Address dw Zs' -g 141 Y1VA4ov1Z7
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Telephone# -2 7 j 97o p
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building_
Other Fixtures
I
No. of persons
Lot Size sq. ft.
Garbage grinder( )
—Showers( ), Cafeteria ( )
Design Flow (min. required) 2. 7_ C gpd Calculated design flow Z. Z ,;� Design flow provided i 3g gpd
Plan: Date S Number of sheets �/ Revision Date d
Title
Description of Soil(s) 4_147A' /
Soil Evaluator Form No. Name of Soil Evaluator •r Date of Evaluation Ai' " /D
DESCRIPTION OF REPAIRS OR ALTERATIONS _� �i ✓ k 4F"R %'Gw Cly e 1,4 e141 f!''/J
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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 ]tl a the syste t operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date `f
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No. r
COMMONWEALTH OF MASSACHUSETTS e (
Board of Health, 1% V G ^t MA.
CERTIFICATE SDE COMPLIANCE
Description of Work: EI'(ndividual Component(s) l] Complete System
The undersigned hereby ernly that the�.ewage Disposal System; Constructed ( ), Repaired
by: �of`^
at 72 Al
has been installed in acce
application No. /0 ` )-_?
Installer Al, /s
raded ( ), Abandoned ( )
C° k /_c"4 ow -k- C " a).
with the pr vision of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated 7 /'t% /0 . Approved Design Flow I %u (gpd)
Designer: /4'vn L.4 e i 1011V161
l61
g cv /. Inspector: r Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. O(„/ `0)..7'7 FEE k
COMMONWEALTH Of MASSACHUSETTS'' `OA
Board of Health, ✓0AuMA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(v) Upgrade( ) Abandon()an indhidual sewage disposal system
at 77 A,/ a /1 ✓ltd � t1 as described in the application for
Disposal System Construction Permit No. /0- dated /"� /G .
Provided: Constriction shall be completed within three years of the date of jthis permit. All local conditions must be met.
Form 1255 Fay. 5/96 A.M. Sulkin Co. Chadegan, MA Dat//er(/C/ /b Board of Health U,� 6 1��
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