HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No. if— ' 53 • 1146 ROUTE 23
C®MM®NVNr''3tAXTSETTS
Board of Health, YARMOUTH , AL4.
FEE IYC
APPLICATION FOP, DISPOSAL SYSTEM . CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairer Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 4/6
Ventura Way S Yarmouth
Owner's Name Sal Elacqua
Map/Parcel#
7
Address 63 Constance : Ave W Yarmouth
Lot#
�/
Telephone# 398-3566
Installer's Name W E Robinson Septic Serv.
Designer's Name
Address PO
Box 1089 Centerville
Address
Telephone#
775-8776
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSbil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
to D -Box and to leachpit.
No. of persons
Lot Size sq. ft.
Garbage grinder PP
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
Replace septic line from back of tank
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 p1pee t system in op ration until a Certificate of Compliance been issued by the Board of Health.
Signed liter w ---Da te
Inspections
No. 98_ y r3 COMMONWEALT14®f MASSAC14USETTS
FEE
Board of Health, YARMOUTH MA
ELACQUA CERTIFICATE ®F COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired �), Upgraded ( ), Abandoned ( )
by: / s ---n/
at 4/6
Ventura way 6 Yarmouth
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ' ¢S 3 dated// - 6 o Approved Design Flow (gpd)
Installer W . o lnson Septic ery CeIle
/t
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gu antee that the system will function as designed.
No.-5� - -ice/ S -G y� O FEE
COMMONWEALTH Of MASSACHUSETTS
ELACQUA Board of Health, YARMOUTH MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct ( ) Repair? Xj Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 4/6 Ventura Way S Yarmouth as described in the aDWication for
Disposal System Construction Permit No. Fd"R5 3, dated _ �'e
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date S" -- T Board of Health