HomeMy WebLinkAboutApp-Permit-ComplianceNo. `� r' /I�� �7Jj /r� FEE U. U
COMMONWEALTH OF MASSACHUSETT
YARMOUTH HEALTH DEPT.7��"
Board of HealtI4146 RnUTE 28 �
o ri,APPLICAT ION FOP,DISP8 t T 19 t Mt RUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade)o Abandon() - ❑ Complete System ❑ Individual Components
Location e
. J -VE
Owner's Name
Map/Parcel#m '
Address
Lot#
Telephone#i�
Installer's Name
Designer's Name
Address
L
Address
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
i
Design Flow (min. required) gpd Calculated design flow : �Q Design flow provided -37]7 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS OR ALTERATIONS
of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur r a to not to pl a the syst in operation until a Certificate of ompliance has been issued by the Board of Health.
Signed Date Q
Inspections 12—X c1 ke ipi—
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FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work:. Individual Component(s) ❑ Complete System ' j 4 -
The undersigned hereby c%tify that the Sewage isposal System; Constructed ( ), Repaired ( ), Upgrade -C Abandoned O
by:
at —.2 -
has
has been installedLn accordancg with the provisions of 310 CMR15.00 (Title 5) and thea proved design plans/as-built plans relating to .
application No. `7 dated -02—Approved Design Flow ' --377(gpd)
Installer
Designer: nspector: ate:.7
The issuance of this permit shall not be construed as a guar tee that a system will function, as designed.
No. C N! �' ! 1. ".r/FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
/)Repair( ) Upgrade- Abandon ( ) an individual sewage disposal system
at V7 V/ �..����j as described in the application for
Disposal System Construction Permit No. �.2' �S 4' /, dated
Provided: Construction shall be completed within +r, of the date of this pe it. All l cal con%diidons �m2usbe met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston; MA Date/// Y Oard Of Health
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