HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HE-A..TH DEPS'.
COMMONI7" 1M i NOW i H, MA 02664
�-- Board of Health, , MA.
FEE �'`.
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APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon() - LIIComplete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address
Lot# Z e3j
Telephone# 3� 'Z •- Q
Installer's Name )`H
Designer's Name fika,
Address AU
AddressAll
Telephone#
Telephone# 6Z -
Type of Building Lot Size 0 Cq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) -G�D gpd Calculated design flow ( Design flow provided J J f gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Date of Evaluation
The undersigned agrees to instW1 the aggiKe described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further es to no t e s in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe Date ^ a S-
Inspections 2-2 -O/ 0-0/� D�
ti
No. 7 C®MMONWE-ALT14®F MASSACHUSETTS � FEE Ida1417
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Board of Health, zlkev-101- ` MA. Aq
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 20tomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( Repaired ( ), Upgraded ( ), Abandoned ( )
by: '9 f, /7 Q�
at j% � U rj Z-t7�T I SJ A-^ ,6 /
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the/approved design plans/as-built plans relating to
application No. 0 / ` -% , dated .Z ` (' Approved Design Flow ri-% (gpd)
Installer yy1� r` CO7t/S n
Designer: ///(%U/�(i �it�Ei(l /.r� Inspector: Date: _ iJ
—The .issuance of -t is_permitshal] not be; construed -as .aguaranteg,lhat the s tem -_functkon.as deli ed,.
gn
No. Q / / e f /7 (-BFEE/AO&O
Board of Health, MA. 40 u,/
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(Rep��aa�iir��( "") Upgrade( ) Abandon( ) an individual sewage disposal system
at 7-)--.p rAtE7�v- /SL tii� ��D//7> as described in the application for
Disposal System Construction Permit No. ®/ % dated
Provided: Construction shall be completed withi mha:c of the date of this p it. All local conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health l
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