HomeMy WebLinkAboutApp-Permit-Compliance, .� YARMOUTH HEALTH [SEPT.
N 1146 ROUTE 28
WHUSETTS
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COMMONWtWWAS
Y _ Board of Health, MA.
FEE
140
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - 'OCComplete System ❑ Individual Components
Location A9 co M $ ri1-o
Owner's Name
Map/Parcel# /-� z,pT12;i
Address
Lot# -�> 7
Telephone#
Installer's Name 1h jp -t- f 0, PC—: S Gz \tom
Designer's Name t 15.
Address C,�;Lo (is )c} , (40
Address
W r -e Lis u0 -V3
Telephone#
Telephone# IfCW
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Type of Building keV1- �'/� � Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)e, 330 gpd Calculated design flow q— Design flow provided_ gpd
Plan: Date C 1 Number of sheets Revision Date
Title ON l -- ------ — -
Description of Soil(s) _
Soil Evaluator Form No.
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Name of Soil Evaluator �U ��� Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS f is 64C.
= 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 the system in operation until a Certificate of Compliance has been issued by the Board of Health.
�igned Date
d
4nspections /0 —Q^ `f� ,/2 s+y�fsc�/ra c24 --
No. 'P— 3 3 FEE
COMMONWLALT14 Of MASSACHUSETTS
Board of Health, V 4,Zy'iti3MA.
CERTIFICAI E Of COMPLIANCE t� oic
Description of Work: ❑ Individual Component(s) �iWomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( }Abandoned O �`
at , c C.; rVO YN r
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and thea proved design plans/as-built pl'ar3 relating to
application No. �, dated 7 r Approved Design Flow (gpd)
Installer`/
Inspector: &'" I
The issuance of this permit shall not be construed as a guarantee that the system will function as designed:
No.
COMMONWEALTH OF MASS C14USETTS
Board of Health, �/ rr (Yr')� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (Abandon ( ) an individual sewage disposal system
at �t G as described in the application for
Disposal System Construetion Permit No.dated: — /
Provided: Construction shall be completed within
nnthrrreeeee mt
years of the date of this permit. All local conditions 1 t be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 77_ PBoard of Health
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