HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
p� 1146 ROUTE 28
SO. YARMOUTH, MA OM4
COMMONS I OF MASSAC14USETTS
Board of Health, , MA.
FEE SCJ c,
' � �pj��1
(i
t1PPL[CATION AOR DISPOS?L SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 15 Q S
Owner's Name J p s
ij L® Ls P 1 h
Map/Parcel# W
Address �S ^� a i
Lot# 9
Telephone#
Installer's Name
Designer's Name S
S,gVytG�
Address f✓Ad
Address 3
l� S vl t
Telephone# 3
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures �q
Design Flow (main. required) 116 1L .3 gpd Calculated design flow 3 to Design flow provided 349 gpd
ItU
Plan: Date OW' 10 / 65 2 Number of sheets % Revision Date
Title
Description of Soil (s) S�f .Sv
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
OF REPAIRS OR ALTERATIONS
01
P"fG'
The undersigned s o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t top a th toop a ' until a Certificate of Compliance has been issued by the Board of Health.
Signed Date a
z7
,Inspections
ip
No. k— l
COMMONWEALT14®F MASSAC14USETTS
Board of Health, U / rrt G r.;,� MA.
CERTIFICATE Of COMPLIANCE
FEE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( )
by: t�I/IS 43f-oT11erJ CC 00 / ',I'-SYa $ LCtl15-C P,
at JSJ Gil) tihc ',, S� , St)tir;, �z,, ice--;�
has been installed i cco ce with the provisions�f 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. q� ' dated / /7 / Approved Design Flow a17 (gpd)
Installer t 1 iS AOGT-�t.-/ C0,10 . cG+ a _
Designer: 4 C M t-si n c! S � �v,'( P �, Inspector: .r �l t.,/ 4WDate:
The issuance of this permit shall not be construed as a guaran/tee that the/system will function as designed.
FEE
COMMONWEALTH OF MASSAC14USETTS 6/S�7
Board of Health,► ! i 't r "A, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (-j Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
St, 50,1
Disposal System Construction Permit No. ��' dated /`^ & -- �4.
as described in the application for
Provided: Construction shall be completed within three years of the date of this p mit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date —� —90 Board of Health /