HomeMy WebLinkAboutApp-Permit-ComplianceNo 30 1 ���G� ) _ ��`G FEE ` ry
f
COMMONWEALTH OF MASSACHUSETTS
Board of Health, *M'DoTa , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
9 Acorn Hill Drive Yarmouth
Owner's Name Lyliane Bower
Map/Parcel#
134
Address 15 Acorn Hill Drive,yarm�
Lot# 19
Telephone# 508-362-7799 Paul TartF
Installer's Name Barrows Excavation
Designer's Name Eastbound Land SurvP_
Address
Queen Ann Rd,Harwich
Address P.O.Box 442, Forestdale,
Telephone#
508-400-6347
Telephone# 508-477-4511
Type of Building Single Family Residence
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Siz� 4 , 8 0 0 sq. ft.
_¢ L�Garbage grinder%o
Showers ( ), Cafeteria ( )
Other Fixtures L /�
Design Flow (min. required) `'/ �-j 11 gpd Calculated design flow Design flow provided 7 7 " gpd
Plan: Date 1125/2015 Number of sheets 1 Revision Date
Title Proposed dwelling Site & Sewage Plans 9 Acorn Drive,Yarmout
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 X4 4t Date
/4"—
Inspectto Mw
No. FEE i
COMMONWEAE10 OfMASSACHUSETTS"
Board of Health, _ 1460T)l , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 6`y c -a t✓b.
at jQc vc- uy' 14 t
has been installed in accordance with the -6 ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . 1 + ApproVed:Design Flow (gpd)
Installer 4, ,
Designer: a tPf�t 'flt'►t'� Inspector: �� ""i Date:. if
The issuance of this permit shA not be construed as a guarantee that the system will function as designed. S
,�:;t ,- •, � i!):: M-..-c.._c. �a-..�--,-'('. . �-..: •: �-Y ::"'^[�. _Y_`3Y� ¢?5 t^�4�, r't "`'`:.-.Y-" t. h', .` v. �"'L PC:'�} (n `,__. .. . �i ., t:�
No. FEE t
COMMONWEALTH OF MASSACHUSETTS �� z� !` " C- �
Board of Health, Yl -+f=& 0 0174 , MA. ;a e
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct (4-)- icepair( ), Upgrade( ) Abandon( ) an individual sewage disposal system
at 4 c, lze) V 14; ILL as described in the application for
Disposal System Construction Permit No. i s-- 0 , dated
Provided: Construction shall be completed within three years of the date of, 's,permit. All local
oc conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date S� Board of Health . `41
i