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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