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HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT. No. 5?`3 •,,-s..,.._._ } 1146 ROUTE 28 FEE SO. YARMOUTH, MA 02664 .. > COMMONWEALTH Of MASSACHUSETTS Board of Health, , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair (,oTUpgrade ( ) Abandon( ) ❑ Complete System ❑ Individual Components Location / / Owner's Name /40- Map/Parcel# ?�j 7 Address Si9%Yl2 Lot# Telephone# 9 Installer's Name Designer's Name f Address 350 Main Street Address Telephone# W. Yarmouth, MA 02573 Telephone# - Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ No. of persons Lot Size sq. ft. Garbage grinder Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) !3 d gpd Calculated design flow 3 3 d Design flow provided gpd Plan: Date /D / o - % % Number of sheets / Revision Date /+ffGSt Title Description of Soils) e� 27 Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS Ae / 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 pace a tem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections 7-38f� COMMONWEALTH. Board of Health, ©�.tvK o e < MA. CERTIFICATE OF COMPLIANCE Description of Work:Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) s�`/(J by: G�- at l 0;,Ql e 4�9� has been installed in accordance with the pr visi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 41 7 -3 C6 8) , dated �::% 177 . Approved Design Flow? S (gpd) Installers K co Designer: ° Inspector: Date: