HomeMy WebLinkAboutApp-Permit-ComplianceNo. -- , YARMOUTH HEALTH DEPT.
1146 ROUTS 28
COMMONWRT04PPMAMUSETTS
Board of Health, YA&A.,MA44 MA.
FEE
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name P(�
Map/Parcel# I cog^/L�
Lot# g S O
//`/
Address1 - .�'
Telephone# _
Installer's Name
Designer's Name
Address
Address Z SC
Telephone# A
Telephone# V /7
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 1.10 gpd Calculated design flow
Plan' Date Number of sheets
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder (j)j
Showers ( ), Cafeteria ( )
Design flow provided 39,V gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
N
further agrees to not to place the tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 1/-. 2./-- 2.ca00
e
Inspections
No. x FEE 0s
COMM6 LAIT14 Of MASSAC14USETTS
Board of Health, _V,44o �, MA. //
col
CERTIFICATE OF COMPLIANCE /`�
Description of Work: ❑ Individual Component(s) V Complete System
The undersigned here certify that the Sewage Disposal System; Constructed ()<), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provisio s of 310 CMR 15.00 (Title 5) and theproved design plans/as-built plans relating to
application Nod rZ , dated ✓ `✓ Approved Design Flow a (gpd)
Installer
Designer: _/�%inspector'..- Date:
u, The issuance of this permit shall xgof'be construed as a guarantee that,4 system will function as designed.
_
No. [ { FEE 6t7-)- C../
- 1 �1
COMMONWEALTH OF MASSACHVS[TTS'i cv# X0 I
Board of Health, t MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby rantedd to; Construct (X) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
,feat / �ux.�L /�� as described in the application for
Disposal System Construction Permit No. .,.dated S%--- e'�
Provided: Construction shall be completed within t•13r f the date of this per • i . All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date - oard of Health