HomeMy WebLinkAboutApp-Permit-Compliance 16 L_D-r4Z- 2.t -004S-1"nI
No. •21 . '1Q 4 FEE
ZI —0 + COMMONWEALTH OF MASSACHUSETTS
I
Board of Health, Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIONtPERMIT
Application for a Permit to Construct()Repair K Upgrade 0 Abandon()-❑Complete System fd Individual Components
Location e T(� c4A, Owner's Name (<LRiLi'\Ki Lx-
Map/Parcel# p.5 Address j( o abs ,ytN42 AiUt6.I. Z.1/4..
Lot# a(., Telephone# -r-
Installer's Name PoeciCr h 6(.1a. co Designer's
Designer's Name SC�` )ev tj I�, tp4406C r4jc_.
Address 3‘3 t v i}cres potra}' 5- 00412. Address 2 2,q e1 N`t�i(�l"f'(.dy E-,14104ect44e1
Telephone# 5 02 4'71. gg 1-7 Telephone# $vim- .133-63 77
Type of Building I E.(D&1)Z/14-(J Lot Size t I t'#vv — sq.ft.
Dwelling-No.of Bedrooms 3 Garbage grinder( )
Other-Type of Building No.of persons Showers(),Cafeteria()
. Other Fixtures
Design Flow(min.required) .3 3 b gpd Calculated design flow Design flow provided 3 3,2;S gpd
Plan: Date 1 I-13-).o,..4..;, Number of sheets � Revision Date
Title S T l PE- CA )L Si;QT Y4Q.a
Description of Soil(s) Al =17itJait S'. 7L�1. SEEP ^/
Soil EvaluatorForm No. Name of Soil Evaluator'ct.a1444.4,4GrE Date of Evaluation_____/21_1.1a 2s610
DESCRIPTION OF REPAIRS OR ALTERATIONS tjSG €)(L T(oe cow .S67Ini .. TpieJt C. •t
.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. I ,
Signed Date a-•—3 -_ 0 . F E 3 0 4 2021
Inspections
fes.• LT','a E-12. In,
No. ' L\ `I/` i• ‘L 1 1 ------ – FEE 5/5
COMMONWEALTH OF MASSACHUSETTS NezeQc.
Board of Health,Yarmouth,MA ----17--4.6-10 .:_ al= eve
CERTIFICATE OF COMPLIANCE . rr Ivor,.4. �'.^
PUMP, e,, l / re r T•r/
Description of Work: ❑Complete System Individual Components r UMP, ARDX t -tet S
The undersigned hereby certify that the Sewage Disposal System;Constructed() Repaired() Upgraded k Abandoned()
by: RO"T t342.,..dz..)
at: g Ttn` LA:4vE 5. Wii2016o iJ
has been installed in accordance with the provisi f 10 CMR 15.00(Title 5)and the a roved design plans/as-built plans relating to
application No. 21-03`4 dated 2./4I -1 . Approved Design Flow (gpd).
Installer: P.er43aCr 0 O de-, �..�� I
Designer:4'C(C� M[(1611,j - T. C_Jnspector: "S. r'h Jq L -t1ja`T 3/ 11 ),)..
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No-- C
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No.- C' I 'IL0/�( J FEE DCD
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct() Repair() Upgrade1\Abandon() an individual sewage disposal system at
S T(D to&t= 5:yA V t�Ti-( LL as described in the application for
Disposal System Construction Permit No. Z)_V 34- ,dated 2�-7 J2QZi.
Provide UM shall be complet-• w't years of e of this permit.All local conditions must be met.
Date 3 � �Wv' Board of Healt, ,' ML:.., ,
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