HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEEr-�^
COMMONWEALTH Of MASSACHUSETTS
YARMOUTH HEALTH
Board of Health, ,
APPLICATION FOR DISPO - ??4RRA--ft9ftCTION PERMIT
r�
L� plication for a Permit to Construct Repair( ) Up radeO Abandon O - XComplete System ❑ Individual Components
11
Location
Owner's Name
Map/Parcel#
_
Address ,S'S� e�� �,Z G L'ty LP jkl E 7F/ -
Lot#
,�1
Telephone# c j 0 �- .
Installer's Name
C
Designer's Name
Address
4
Address
Telephone#
Telephone# ,_
Type of Building �\ L� ' `� Lot.Size � , d sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) design flow Design flow provided gPd
Plan: Date Numbya4culated
r of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr t n t e i er tion n' ttfilcate of Compliance has been issued by the Board of Health.
Signed / Date
s
No.
Description of Work:
The ullcnsign d here
by:
at �� 14
has been installed in ac
/ ,ap Illic�attio No.
�`i L�-'/Installers
COMMONWEALTH Of MAYS(/SACHUSETTS
Board of Health, V ol(IW -/ 41 , MA.
CERTIFICAf E Of COMPLIANCE
❑ Individual Component(s)mplete System
by certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Up
Designer: / /U 44-1
The issuance
/of this peri
No.
with the ro��sions of S10 CMR 15.00 (Title 5) and the
dated TIP `P `/h . Approved DesiQ°n Flow 4!1175
�Y�i�Ll7% Inspector:
01 shall not be construed as a guarantee
FEE
r
( ), Abandoned ( )
,qar-
design plans/as-built plans relating to
zl /qVArjif Date: _
the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, \/a Gam'' , MA.
DISPOSAL SYST CONSTRUCTION PERMIT
FEE
Permission is hereby/�g/rantyd to; Construct( )� Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at "�� U /�( .//�L��ff`` j/i�%/3 �l%G', , as described in the application for
Disposal System Construction Permit No. A0 -/b(,' ,dated 6 - A�10 .
n -t
Provided: Construction shall be completed withikree of tdate of this permit; All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date �� �� Board of Health r!
-n ci