HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEP*i
No } —✓' 1146 ROUTE 28 FEE
SO. YARMOUTH, MA 02664
Gri Bob` ®MMONWEALTH OF MASSACHUSETTS � (ate
C�
J� Board of Health, 1CY)l 1H AM,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(/Abandon( )-/fComplete System ❑ Individual Components
Location (� ah�J j��('
Owner's Name
Map/Parcel# 3 W
Address 2-3
Lot# 2-11 U 1 S
Telephone#
Installer's Name ` _C S C 1 C-
i
ff
Designer's Name d- L a S
fl hn �.►, C 4-'S,
Address k �U p t S
Address
-33 pLs ma;\,
Te
Telephone# Sd 0
Type of Building g e_ �, 6Q. :N, 0.\ Lot Size
sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. ofersons Showers
p (), Cafeteria ( )
Other Fixtures
Design Flow (min. required) S gpd Calculated design flow Design flow providedJ—Cl gpd
Plan: Date /d _ / '� % % Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
: 0ows,z- SokK�
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
J# Ic�x�m
Date of Evaluation
The undersigned agrees to install the abovoodescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furiher agrees to not t mo er 'o til ertificate of Compliance has been issued by the Board of Health.
Signe Date
P
Inspections
COMMONWEALTH Of MASSAC14USETTS FEE s� .
Board of Health, �_, 1►L4. G
CIRTIFIC�* Of COMPLIANCE
Description of Work: ❑ Individual Component(s) *Complete System
The undersigned hereby certify that the Sewage�Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( )
by: M 1 � — C ki (= �_!= P 'I / C
at l %it) / I. 0' (.J 17 A h.) P 1W A 1G: �'
has been installed in accordance with the proN
application No. Y7- '9(-�V -, dated
Installer M \ 0-S -CA 0 G
Designer: X4 -1"m C. K,t i sev-utee5
s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
Approved Design Flow S 6 (gpd)
tor: 6�111he*PFF11rA 'F /3t;` Date:
0
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