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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE t " . 00 COMMONWEALTH OF MASSACHUSETTS Board of Health, YARMOUTH HEALTH D1146 MUTE 219 1: , 1GIA. S APPLICATION FOR DISP099WIMM M6MMUCTION PERMIT Lplication for a Permit to Construct( ) Repair( ) Upgrade )0 Abandon( - 'Complete System ❑ Individual Components Location Owner's Name e Map/Parcel# 3/ /,r d Address Lot# Telephone# Installer's Name e Designer's Name 100., Address,,.,,���, Address ��+ y� `f, J71 Telephone# f`�j� �'� f,��(`6 Telephone# Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) `� © gpd Calculated design flow -33 a Design flow provided gpd Plan: Date 1�/ Number of sheets Revision Date d Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation LI AZ' fJ DESCRIPTION OF REPAIRS OR ALTERATIONS _Z�"� i ��G �L 7�°�/� J ` `� C 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 system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date �� �� Inspections _. wgxa No. COMMONWEALT14 Of MASSACIIUSEM � ��-oo er-,. 4 Board of Health, MA. o, CERTIFICATE Of COMPLIANCE Description of Work: U Individual Component(s) W Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded ( ), Abandoned ( ) at has been installed in accordance with the provisions of3 0 CMR 15.00 (Title 5) and the a2proved design plans/as-built plans relating to application No. I% �/� dated (42 � 3 �� Approved Design Flow _= (gpd) Installer 7—, ;..1 ` - Designer: /`�% G; �d �� Inspector r' t %' Date: gf- / --L The issuance of this permit shall not be construed as a guarantee th_ the system will function asslesigned. No. � �I ,-��`�l /�� FEE 00 COMMONWFALTII OF MASSACI4USETTS /7f1 Board of Health, i'�it , MA. ➢FISP®SAI. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade O Abandon ( ) an indixidual sewage disposal system at,/ J as described in the application for Disposal System Construction Permit No. //—//0 , dated Provided: Construction shall be completed within tdlt�-of fhe date of this pga}zit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chaaddestown, MA Date •-� :-- '' ry�'� Board of Health %x~f ��/ �� /