HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No.
1146 ROUTE 23 FEE
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSACHUSETTS ,� C
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (✓) AbandonLI-Complete System ❑ Individual Components
Location 3e Ever r�.�hl6-1, c„r
Owner's Name C�iv,6t�,
Map/Parcel# ,� -
Address _r=iW—j c; ;4 y.,J ND
Lot# /\� — �./;
Telephone#
Installer's Name DP —
�^CY�I �SE�tC.
Desi ner's Name `
g i�,+Y`tV L.c.,.,.Q..Sc-rVCLes.
Address
Address
Telephone#
Telephone#
Type of Building IZ e Sl cQ tv cg_ Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 30 gpd Calculated design flow -3k.0 Design flow provided 33'� gpd
..Plan: Date iil fly Vi' L61,°l 7 Number of sheets Revision Date
Title C A M .i v�
Descr,iption of Soil(s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS
a
Name of Soil EvaluatorDate of Evaluation
e
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n t to place the system i 55�o e��ration u a Certificate of Compliance has been issued by the Board of Health.
Signed1j",de �--V Date
No.� FEE—;��',.L=t"Gm.✓
OM ONWEALT�� OF MASSACHUSETTS
Boatel of Health, r otic NIA.
P11
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) P Complete System
t
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded " Abandoned ( )
by: jve
at S^, t,
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and ]thea roved design plans/as-built plans relating to
application No. dated 6 :.%lfj . Approved Design Flow (gpd)
Installer 011b
Designer: -5 4Z /s9. -rt - .._(Z_=V6L1jf.fZ-,Sispector:
mL_G__.-_____e.u__v_.. L_ -------- A__-. -.-_..
Date: ✓`.� • i/"�/°