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Board of Health, )!�A2M0 UT11 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct() Repai�()0 Upgrade Abandon() - Ll Complete System M Individual Components
Location 822 Route 28, S. Yarmouth
Owner's Name
822 Realty Trust, J. Hynes, Tru
Map/Parcel# 33-70
Address 822
Route 28, S. Yarmouth, MA 02664
Lot#
Telephone#
508-771-0100
Installer's Name `.
Designer's Name The BSC Group, Inc.
Address
Address 349
Route 28, W. Yarmouth, MA 02673
Telephone#�� ' Fj �� -
Telephone#
508-778-8919
Type of Building Motel / ,t 1 ��� is✓j2s 3 OA -V Lot Size sq. ft.
Dwelling - No. of Bedrooms CSS / - Z of ` L 3� Garbage grinder (NOD
Other - Type of Building N . of per onf Showers ( ),Cafeteria ( )
Other Fixtures 5/ dLl �% ' f mm. , .Z f-2-0
9"Oel
Design Flow (min. required) 7,920 gpd Calculated design flow 7,920 Design flow provided 7,920 gpd
Plan: Date 2-14-14 Number of sheets 1 Revision Date
Title Septic component repair, 822 Main Street, EAST SIDE, South Yarmouth, MASS
Description of Soils) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Replace existing undersized pump chamber with a conforming pump chamber
The undersigned agrees to install the above described Individual
,further
agrees to to place the system in operation until a ex
Signed
Inspections
uge Disposal System in accordance with the provisions of TITLE 5 and
of Compliance has be issued by the Board of Health.
i- 60CSL 11 P7,147
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No.— kICOMMONWEALTH Of ��- As ,IFE -
SETTS
,r
Board of Health, \ ! ., „ . ; MA. 7
CERTIFICATE OF COMPLIANCE
Description of Work: PAfidividual Component(s) 0 Complete System �— �-
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded' ( ), Abandoned( )
by :/
at "" R: iz4 n S C vi } Yn trn t±}t
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. �iZ1. dated �. Approved Design Flow _(gpd)
Installer
Designer: // /. Inspector: Date:
The issuance of this permit shill not be construed as a guarantee that the system will function as designed.
No.Cd _ ��J�/ �I L= -/ w- "^ FEE - l�
COMMON LTH Of SSACIIUSETTS
Board of Health, �� fes_, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 8,)2 ;a n„ t r 0 ?2, 17.:.,, rl, v:: , .. as described in the application for
Disposal System Construction Permit No. f-- , dated
c
Provided: Construction shall be completed within tlQO�s c iP the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date 2 Board of Health is