HomeMy WebLinkAboutApp & Permit No.D4C.22' 9 Zey--L___• -- FEE
CO I j OlNWE'ALTH OF MASSACHUSETTS
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w. _. • Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION; PERMIT
Application for a Pennit to Constnict()Repair(/pgrade()Aba4don()-❑Complete System ndividual Components
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Locaiior� , S l� �� Owner's Name 3r�a� f-a ;�' nn �'�9n
Map;Parcel# lqQ 17 `2/ _ct)`), 499. 7 Address �' /�3j (rave/4 Cc). nl i-,:;) v- -
Lot# 5 if G• Telephone#`=��yi &81 _ c./L(
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Installer's Name Ref 40 l (tL (\ i JI Designer's Name )n j�/�e 7
Address Address ��C ���' I...►
P�.�X 70( 06 9aji�a/n , G� Q
Telephone# ASO 7/- �9 I Telephone# g-- 36o�)• �/6 t/J i
Type of Building bcep l&1[ . IZD6Jefidia.1 1 ^�1 _Lot Size, 7�3a sq.ft.
Dwelling—No-of Bedrooms 11 y pe&rc 17i 4e.)4-01 6 + 3) Garbage grinder( )
Other—Type of Building No.of persons Showers(),Cafeteria()
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Other Fixtures
Design Flow(min.required) gpd Calculated designflow (4 WO Design flowprovied up
Plan: Date ILA. .h 1 Number of sheets ' Revision Date N/A-1
Title i
Description of Soil(s) QIQs 1 /�n�
Soil EvaivatorFormNo. Name of Soil Evaluatota'Q pros; Date of Evaluation d/ 17/at;.
DESCRIPTION OF REPAIRS R ALTERArONS Ilit f )-6, / A - [ /i /Y l aV /(/�/k )
-Ro,n IC �Q ii. A `r n }t1e # (tJ o .pr 77-llof
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.The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the pr ' ;Mand
farther agrees to not to place the system in ape-.tion until a Certificate of Compliance has been issued by the Board o r�ea t i.
Signed. Date gl.�� MAR 14 2022
Inspections HEALTH DEPT.
No.
22 ' 392
FEE
COMMONWEALTH OF MASSACHUSETTS
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Board
Board of Health, Yarmouth, MA — 6,„t_T-
ISPOSAL SYSTEM 9ONSTRUCTION PERMIT
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Fermis ' n is herelyy)grantecl t Co ,§tuna( ) Repair[/( Upgrade() Abandon() an individual sewage disposal system at
i 1 r/1�j'' (Y 9L ��• X�i —/ as described in the application for
Dispos- • .stem Construction Permit No. ZZ-G6. , dated 4 /i f zo2 . _
Provided: Construction shall be completed within t.i.cc;cars of the date of this permit. All local conditions must be met.
Date 4 I 11 2O zz- Board of Health S l-t-zcti-J 1-i--,/ -/A-