HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. - 1146 ROUTE 26 FEE
5®. YAR9 O'UTH, SEA 02664
'COMMONWEALTH OF MASSAC14USETTS
Board of Health,�T , MA.
a
APPLICATIO FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System ❑ Individual Components
Location
-MR19 i"e,
Owner's Name
Map/Parcel# a` /.Z—
Address
hane —--
Lot#
Telephone#
Installer's Name
Designer's Name
t n
Address J
Address
Telephone#
Telephone#
�' I
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The underiigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further s to not t plac a eopedran a Certificate of C m Haug has been issued by the Board of Health.
Signed Via � `�� /G'tzV7— Date
Inspections
No -9 "246 COMMONWEALTH Of MASSA( TSETTS FEE ��
Board of Health, MA.
CERTIFICATE Of, COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by.
at
has been installed in accordance wi tlf the provisions of 10 CMR 15.0 (Title 5) and the approved design plans/as-built plans relating to
application No. y dated 6 Z Approved Design Flow (gpd)
Installer jolk M — r - 1.
Designer: Inspector:
The issuance of this permit shall not be construed as a guard
Date:
that the system'Will function as designed.
No.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, �` , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( )
at
_fir
FEE 4•C/CJ
( )
Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. 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 Health