HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. q'� 0 1146 ROUTE 28
- SO. YARMOUTH, MA 02684
aw A/1P'zz?OMMONWEAL1H Of MASSACHUSETTS
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Board of Health, UQ�,��q , MA.
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APPLICATION fOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeX Abandon( ) - Xcomplete System ❑ Individual Components
Location / H 6 CAC D�
A44
Owner's Name DA14&M,arj!rjjPAej,1*
Map/Parcel# /PIAP /03 f'�;,ecxk y%®/
Address ,/ t -&AR.Suck ,44,vo
Lot# 14-
Telephone#
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Installer's Name C
Designer's Name
Address
Telephone#
Donald W. MOncevicz
Civil Engineer
40 Pond Street
West Dennis, MA 02670
Address 9 2
Telephone# rz Q e c
Type of Buildinga��rV L Lot Size la, B6' C sq. ft.
If
Dwelling - No. of Bedrooms ,��5/ GA., !�Qe Garbage grinder ( Al®
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ( _ gpd Calculated design flow _ � ® Design flow provided -333.:7 g1k*
Plan: Date ,Jc,,;rft /0 / ?qA Number of sheets Revision Date
Tid l�
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator b.W 04gAWWICZ Date of Evaluations-AwI- I Q
2%CIS/iti'G .eVSIWM fAJ WI'A�j�k''7'l�J�/-�. %C�i�f�lt•Ae�c'
DESCRIPTION OF REPAIRS OR ALTERATIONS
vn�DUFi' ," A S.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to not to place the system . operation until a Certificate of Compliance has been issued by the Board of Health.
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Signed L Date
Insaections
No.
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Board of Health, btJi'�/ MA. A /
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CERTIFICATE Of COMPLIANCE 2
Description of Work: ❑ Individual Components)Complete System
The undersigned hereby certify ;that the Sewage Disposal System; Constructed )(, Repaired ( ), Upgraded ( ), Abandoned ( )� t
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. R— �t? ,dated. Approved Design Flow (gpd)
Installer /
Designer•. W%iam1"1—, Inspector•
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. (Q �P1G� �%�//SZ/1� 4/„5..5-41~'6-'" FEE
COMMONWEALTH Of MASSAC14USETTS C b#
Board of Health, , MA. ` ;(
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at d as described in the application for
Disposal System Construction Permit No. `f dated'
Provided: Construction shall be completed within three years of the date of this permit. Alllocalconditions must be met.
Form 1255 Rev. 5/96 A.M..SA16 coy Boston, MA Date .7- -logoard of Health