HomeMy WebLinkAboutApp-Permit-ComplianceZA-a —Z�
FEE'' MASSACHUSETTS ,S�
OMMONWEALTH OF
YARMOUTH HEALTH DEPT.
Board of Health, 11ee o01 rrC 98 MA.
APPLICATION FOR DISP09RMft'R1- MMUCTI®N PERMIT
Application for a Permit to Construct Repair( ) Upgrade X Abandon( - Complete System ❑ Individual Components
Location
Map/Pa419.31Z
Owner's Name f!�iicj+ ff. P7mw %i t4
Address LW —fmw
7�rc�e+l#
M 4"ttJ
G0fqCVN o
Telephone# •i'�'' C/ � �. i'49403co
InstalIer'sName ��/t,,j C �/ S-CL,f /�
Desi ner'sName
.
Address mST'®,.H
Addressd het'npo�
Telephone# Slo
`?'7 & — ®
Telephone# � -344-0olq
Type of Building /'6:51 D-4 Z7A/- Lot Size _jAJIA sq. ft.
Dwelling - No. of Bedrooms o� /GN F*Q& Garbage gxrinderA/,
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 42. „Z92— gpd Calculated design flow 3 3n Design flow provided gpd
Plan: Date M90 %?. X00 d? Number of sheets ® Revision Date
TitleRa0P&S97D ---5AAJ17-n1-eV 5YX7-i= M (.. ,*AA*-Ja0=
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaliiatorr`�'
of Evaluation L'9&7? 1 , Z
DESCRIPTION OF REPAIRS OR ALTERATIONS Ad E5" jcn A4 e �s � 1��► �. �'2+i �3�'
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 a tem operation until a Certificate of Compliance has been issued by the Board of Health.
Signed • Datet"
Inspections
No. _ p FEE s' J
COMMONWEALTH OF MASS
Board of Health; ,`Q' .r'vi @ MA.
CERTIFICATE ®f COMPLIANCE
Description. of Work: ❑Individual Components) Complete System
The undersigned hereby certify that the Sewage DisposalSystem; Constructed;, Repaired ( ), Upgraded (A, Abandoned ( )
by:
atre- y%
has been installed incco d/a ce with the provisions of 3V CMR 15.00 (Title 5), and the approved design plans/as-built plans relating to
application No. Q - / , dated %f �� 'e� �. Approved Design Flo (gpd)
Installer hi►
g. A0cc Inspector: Date: Y00Desi ner:
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
co
No. !v�� 1
FEE
'Board of He�alth,' ,NIA.
DISPOSAL STST CONSTRUCTION. PERMIT
Permission is hereby granted to; Construct Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at Ave -& ®GJ s described in the application for
Disposal System .Construction Permit No.dated /f--<6'�1 �no
Q
Provided: Construction shall be completed within th4��-of the date of this per All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston; MA Date
//Z ,7) Q Board of HealthA