HomeMy WebLinkAboutApp-Permit-ComplianceNo. _��JC FEE
AW11 7V COMMONWEALTH OF MASSACHUSETTS
YARMOUTH HEALTH DEPT.
l C S Board of Healt, 146ROUT�� , MA. J(/ r�'P / � - /�O)C / Z.�
APPLICATION FOR DISPMMR"ttffiMTRUCTION PERMIT
Aplication for a Permit to Construct( ) Repair(P<Upgrade() Abandon() - ❑ Complete System ❑ Individual Components
0
9
Location `
Owner's Name
cl
Map/Parcel# Z
Address f
Lot#
Telephone# F-- P&
Installer's Name
Designer's Name
Address
Address A& f� ,
`di'
Telephone# � � 3 �_ y�l
Telephone# s _ 3&_
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) llyd gpd Calculated design flow 4KAl2 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
'1:'e undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to not to plac the system in operation u til a Certificate of Compliance has been issued by the Board of Health.
=Signedr 1 r Z4-4 Date
I
Inspections _
yffaw-A
No.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
CERTIFIC-4*nor COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed'( ), Repaired (v*�, Upgraded ( ), Abandoned ( )
by:
at ¢
has been installed in accor x}ce with the rov' ions o310 CMR 15.00 (Title ) an th, -pp oved design plans/as-built plans relating to
/ ,dated Approved Design Flow ��2�r' " (gPd)
application No. Q`
Installer L
Designer: Inspector: 94Z Date: ! fff%
The issuance of this permit shall not be construed as a guarantee that the system a function as designed.
No. //A- FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, (lif.i2� MA.
DISPOSAL SYSM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( -O* } Upgrade ( ) Abandon ( ) an individual sewage disposal system
at % 71' _ ��A ��/ as described in the application for
Disposal System Construction Permit No. 7 dated
Provided: Construction shall be completed within �s of the date of this it. All local conditions must be met.
�_�_��
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA �^ Dante � Board of Health � �i`/
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