HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. - 3 1146 ROUTE 23 FEE
SO. YARMOUTH, MA 02664
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �T , MA.
APPLICATION
FDP DISP®SASYSTEM CONSTRUCTI®1NPERMIT
Application for a Permit to Construct( ) Repair( )/ Upgrade( ) Abandon() - LlComplete System V.dividual Components
LocationOwner's
Name
�c� ./C�iG (//✓ �%
Map/Parcel#
Address -
Jtf f� w 0
Lot#
Telephone#
_._. !�e�5—ll
Installer's Name�
Designer's Name
Address
14 dress
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIOKS J bX% `-���''
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notbpoaUe the sys inMa Certificate of Compliance h beenis uy the Board of Health.
Signed Date
Inspections
No.�
COMMONWEALTH
/��/� �T��rE �~ m 1�(� T FEE / �L
SETTS
Board of Health, Ci% , MA.
-CEPITIFICAt' O*F COMPLIANCE
Description of Work: Individual,C`omponent(s) ❑ Complete System .
The undersigned hereby certify that the Sewage Disposal Sys; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at %
has been installed in accordance with the ovis'onss.o 310 CAR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / 1A , dated 71 A proved Design Flow (gpd)
Installer Lam/ v� / S
Designer: Inspector: Date: O :•a �n 'u
The issuance of this permit shall not be construed as a guar tee that de system will function as designed.
No. �lS rJCOMMO�7��j G= �jZ t S
' . {�¶¶�7 FEE /� L
4 Of
SETTS
Board of Health, ot/?MA.
DISPOSAL SYST& CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair() Upgrade( ) Abandon( ) an individual sewage disposal system
at ._i�.'c� ' "�% as described in the application for
Disposal System Construction Permit No. 3 , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date %�� Board of HealthC