HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0F
7-15- ��«.I tax- ok l - l � � F ,
Zo
YARMOUTH HEALTH RAPT. MASSACHUSETTS'COMMONWEALTH OF �
Board of Health,1146 RE)UTE 28
, MA.
APPLICATION FOR DISP®SWI M tf1fflWCTI N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(kj"Xbandon() - ❑ Complete Systemindividual Components
Location /
Owner's Name
Map/Parcel# /d 4�s ���
Address
Lot#
Telephone#
Installer's Name
Designer's Name r�✓!/'eLi/L�
Address3d
AddressP
Telephone# 6-0 $P-, 3 ��
Telephone#
Type of Building y� Lot Size sq. ft.
Dwelling - No. of Bedrooms 7 b-,Pg4w Ar Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided `7V gpd
Plan: Date . Number of sheets Revision Date
Title
Description of Soil(s) egg a OU" 4
Soil Evaluator Form No. e Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 place the system in operation a Certificate of Compliant has been issued by the Board of Health.
Signed Date 1 Id
Inspections
No. �d % FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, , MA.
CEI TIFICAOf COMPLIANCE
Description of Work. YIndividual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; �Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
at
has been installed in accordance with the provisions of 31"MR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated -. 6 /'0 Approved Design Flow 3!0>'7_(gpd)
Installer /zry g r..
oft
Designer: " - -- v Inspector.' ir? Date: — `
The issuance of this permit shall not be co&X7ued as a guarantee that the system will function as designed.
No. �U / � C!/� � / �"�'� FEE J,7
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYST& CONSTRUCTION,PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (d--)' Abandon( ) an individual sewage disposal system
at f _ _ _ as described in the application for
Disposal System Construction Permit No. , dated7–.26 /'O
Provided: Construction shall be completed within tie -e eas of the date of this verit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesown, MA Date / %UBoard of Health