HomeMy WebLinkAboutApp-Permit-Compliance~ No. J
FEE
%cCOMMONWEALTH OF MASSACHUSETTS
YARMOUTH HEALTH DEQT�
Board of Healthl ,'MA.
146 ROUTE 28
APPLICATION FOP, DISPMARVATWOM4RUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System Zdiidual Components
Location ,
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Owner's Name Oe_01
Map/Parcel#
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Address SA✓^ -9,
Lot#
Telephone#
Installer's Name -3A wa—
Designer's Name
Address
P �JOx
/ if OS-fe.,✓,
Address
Telephone#
15-01
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Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
DESCRIPTION OF REPAIRS OR ALTERATIONS (W Y CP- 0A1
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
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.
Signed Date
Inspections
No. li% �J S FEE / V
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA. 9 �/
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: �iQ- 3 \' G
at / y C W (, S �' - (3Q x (+(�
has been installed in accordance with the pro sionj of 310 CMR 15.00 (Title 5) .and the approved design plans/as-built plans relating to
application No. �_` w Z- dated 7 Q / Approved Design Flow (gpd)
Installer
Designer: Inspector: Date: l�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE
COMMONWEALT14 *OF MASSACHUSETTS
p �60 /
Board of Health,
DISPOSAL SYSTEM CONSTPU.CTIQN PERMIT
Permission is hereby granted to; Construct( ) Repair ✓j�Upgrade ( ) Abandon( ) an individual sewage disposal system
2�, I -
at � � Gin 1^ (.nJ l ►S g r ep A, ( as described in the application for
Disposal System Construction Permit No. , dated /0
Provided: Construction shall be completed within 4h - -- f thef ate of this permit. All local conditionsmus t be met.
Form 1255 Rev:. 5/96 A.M. Sulkin Co. Boston, MA Date
�� _ (/ / Board of Health