HomeMy WebLinkAboutApp-Permit-ComplianceNo. '(o'" 3 �o ` ', 1146 ROUTE ZB
30. YARMOUTH, MA 02664
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (�,Kupgrade( ) Abandon( ) ❑ Complete System ❑ Individual Components
Location-YY a r m o u t h p ort, Ma
Owner's Name Jerry L. Fine o l d
Map/Parcel#A. M. 100/B3
Address 56 Main St. Yarmout ort
Lot#
Telephone#
Installer's Name n Cash Cash Trucking
Designer's Name Ronald
Address Off Union St. Yarmout
Address Box 258, W. Yarmout, Ma
Telephone#
Telephone# 775-9700
Type of Building r)WP 11 1 i n g Lot Size sq. ft.
Dwelling - No. of Bedrooms 4 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 455 gpd Calculated design flow Design flow provided 4 5 5 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS T n.-, i- a 1 1 i n q a 1 P a r- h i n n a r Q a US i n- 2 3 8'
long by 2.5' wide by 2' deep stone leaching trenches. Using
29' of perforated pipe pitchpd @ 1/16'1/ft far—each trench
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire o not to place th system in ope ation until a Certificate o Compliance has been issued by the Board of Health.
Signed Date
Inspections
No.
/
/�
�®�'l MONWEALTH Of MASSAC14US�ETTS FEE
Board of Health, vH MA.
CERTIFIC COMPLIANCE
Description of Work: ❑ Individual Component(s) Urem iplete System U
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ) , Repaired (-) Upgraded ( ) , Abandoned ( )
by: C (AS
(�f�
atm!
has been installed in accordance with the 7f,;i-
visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. -G• ^ 3G % , dated 1Approved Design Flow yss (gpd)
Installer C b4 S
Designer: Y tarti/ Z- Inspector: foe Date: X14 "'t�,� {�►
The issuance of this permit shall not be construed as guarantee that the system will function as designed.