HomeMy WebLinkAboutApp-Permit-ComplianceS No.
COMMONWEALTH Of MASSAC14 SETTS
Board of Health, Yeo A , MA.
4
FEE
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(�rade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name d
Map/Parcel#
3 p
Address
Lot#
99
Telephone#
Installer's Name
Designer's Name S
Address
350 Main Street
Address
Telephone#
W. Yarmouth, MA Q2W3
Telephone# C[ 3 a .• ^S6 S
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
'e S .
Other Fixtures 7
Design Flow (min, required) gpd
Plan: Date Number of
/7 . I
Title
Description of Soil(s) _
Soil Evaluator Form No.
Calculated design flow
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS �—P_ C:
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date_ A)
Date of Evaluation
The undersigned agrees jo ins e a ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not tk p ce a tem in o eration until a Certificate of C mpli i been issued by the Board of Health.
(Signed Date 0
Inspections
No. FEE .)
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �,Y 6 1 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (graded ( ), Abandoned ( )
by: IL - 0
at aj
/ it , it . b-�;, - 3�—'ell 2
has been installed in accordance with the provi onn1s,0.310 CMR 15.00 (Title 5) and the p roved design plans/as-built plans relating to
application No. ! `� , dated IV -64 Approved Design Flow (gpd)
Installer CX -I,((- C ;-o /--,,_- \ _
Designer: Inspector: %�li�.. Date: l'� tj �c ` ,✓1°~0
The issuance of this permit shall not be construed as a guar _tee tha the system will function as designed.
--- --- _
No. �/ f ��v( yZ.c.''�✓ FEES
COMMONWEALTH Of MASSAC14USETTS COV -f �31/
Board of Health, 0 � /4fJ(/4 /I MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby anted to; Construct( ) Repair(Upgrade( ) Abandon( ) an individual sewage disposal system
at % 1"r/ /)(/ Yl ,S II—) . � �d Yip as described in the application'for
Disposal System Construction Permit No.�, dated -149
Provided: Construction shall be completed within t4�r& the date of this pe it. l local condid s must,be met.
orm 1255 Rev. 5/96 A.M. Silkin Co. Boston, MA Date %G� V Board of Health G,