App-Permit-Compliance 13LD►12'-21-v0I 5-n
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2.No. E_F
2° ^231 COMMONWEALTH OF MASSACHUSETTS CIS--I (2I4+
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Repair Upgrade()Abandon()-O Complete Systemt/lndividual Components
Location 19 g Cpr}c rs Sr> tr; Q,oad, Owner's Name Coa 61 SGO•A (.hwtnot
Map/Parcel# 11' 3 V Address 21 pi k°moos, b1 4 V Sc
Lot# SS Telephone# M. Z• KM
Installer's Name ' Designer's Name
�d '�xcu�k+oma Iqc.. � Staeokser Con9enifor:
Address Ili Rom 13o S4�d t IL#, Address 2.03, soturAi.i Rd. NZ
Telephone#&01• kill, 0.63 Telephone# S•o$• 3 S• (0/100
Type of Building Nis. d.aalt•nk Lot Size t o, I SIo sq.ftf'/.
Dwelling-No.of Bedrooms 3.__ �_�_ p Garbage grinder O
/�/�
Other-Type of Building „`k/•y W A ,,, ��
Tlva No.of persons Showers(),Cafeteria()
•
Other Fixtures DL
Design Flow(min.required) 330 gpd Calculated design flow Design flow provided ISI gpd
Plan: Date q (s(2.0 Number of sheets I Revision Date
Title
Description of Soil(s) Sot f1tcr» ,
Soil EvaluatorForm No. Name of Soil Evaluator Swath SK Date of Evaluation Stet. a. 2.o
DESCRIPTION OF REPAIRS OR ALTERATIONS taf 04a M,V d•box 000 St4i CAnnitch(6 4•p
Q' ".k" )b 1000 3.ltott,. %1`.
r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the prop inions of T1'f'tB 3 arrd' —
further agrees-ton t to place th system in operation until a Certificate of
Compliance has been issued by the Board of I lealth. ... _ IsL\ '-_%I
Signed q/ Date 'llJ=I2o SEP 2 8 2020 a
Inspecti s
HEALTH DEPT.
130P-DC-DC • 1,5 - 03(126 zONle- u:c FEE
COMMONWEALTH OF MASSACHUSETTS N S " • Ole---
4
Board of Health, Yarmouth, MA K
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Complete System dlndividual Components
The u dersi ned hereby certify that the Sewage Disposal System;Constructed() Repaired(4'Upgraded() Abandoned()
by: lei9 tictaUodi %U..at: ►y4 mAi►
has been installed d a accordance with the prov ions f 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application No. ZO-2.31 ,dated q�2 Approved Design Flow,351 (gpd).
Installer:
Designer: Inspector: Date:
The issuance of this permit shall not he construed as a guarantee that the system will function as designed.
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission i hegr by•grante to; Construct( Repair("Upgrade() Abandon() an individual sewage disposal system at
lye is
SMa►11 Road as described in the application for
Disposal SysteConstruction Permit No. 20-2.3 1 ,dated
Provided:Co gtrructtiiion shall be completed within thre- years o - rate oft is permit. All local conditions must be met.
/ W
Date 10 / ZOard of Health itr! _.•1111P110
Commonwealth of Massachusetts
Board of Health, Yarmouth, MA Fee
CERTIFICATE OF COMPLIANCE $55.00
Description of Work:
The undersigned hereby certify that the Sewage Disposal System; Upgraded
by: B&B EXCAVATION,INC.
at: 148 CAPT SMALL RD, SOUTH YARMOUTH,MA 02664
Has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved
design plans or as-built plans relating to application No.: BOHDC-20-0368,dated .
Installer: B& B EXCAVATION, INC.
Address:14 TEABERRY LANE FORESTDALE,MA Inspector:
02644
Designer:
for ,r ,_s° /C12/ 702-0
. Mu 41, PH, R.S., CHO/Mallory R. Langler, R.S.
Health Director/Assistant Health Director
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
BOH_Disposal_Construction_CofC.rpt