HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH LTH ®F MQAgWTT
YARMOUTH HE
Board of Health) idr, R01 LTE 28 , MA•
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APPLICATION FOR DISA�Mm. R TIS
pplication for a Permit to Construct( ) Repai� Upgrade( ) Abandon() - ❑ Complete System
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Location >
Owner's Name G j .as('
Map/Parcel#
Address
Lot#
Telephone# �`t5g - ` y 3 71
Installer's Name
Designer's Name C o _
Address S
-K�t
ej
Address me,
Telephone#
ne#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
gpd Calculated design flow
Number of sheets
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date __-
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator j_ Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
a further agrees to not t lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date?-/ b I
Inspections
No.FEE
'l_®MM�� W) OF MASSACHUSETTS
s
Board of Health; liG , MA.
CERTIFICATE F COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired (, Upgraded ( ), Abandoned ( )
by: C - k) K�e_
at
has been installed in accordance with the Drovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _2-11. Approved Design Flow-" (gpd)
Installer
Designer: Iujspeetor: L% l�ly� Date:
The issuance of this permit shall not be construed as a guarantee anteat the system will function as designed.
a
No. J FEE
COMMONWEALT SSACHUSETTS
Board of Health, GL , MA.
DISPOSAL SYST C®NSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair X) Upgrade ( ) Abandon( ) an individual sewage disposal system
at \\ _1 t S f as described in the application for
Disposal System Construction Permit No. �7� , dated 4�_Z -'/ 1
Provided: Construction shall be completed withinre ,years of thLate of this it All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 2 ^ Board of Health