HomeMy WebLinkAboutApp-Permit-Compliance ?b\\. -24 .00tp1'S2
No.a , Z I • 35_,20 FEEf"_
c'.77 I - I2_ _ COMMONWEALTH OF MASSACHUSETTS 4 2021
Board of Health, Yarmouth,MA MAY
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Q^ 1(PPLIC,ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM Tp DEPT.
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Application for a Permit to Construct()Repair()Upgrade 0 Abandon 0-0 Complete System 0 Individual Components
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LocatiI- Avg Owner's Name ��5 Ke ItMap/Parcel# �3 / a Address ab wail�Qe Avg
Lot# Telephone#
Installer's Name Ro bQ t4' g ova_ Designer's Name Donal t! IA) r,,0()ca.) i C Z
Address 27s. ,33 Lok4475all, Address 40 Pond 5treQl i (Dennis
Telephone# SOC-47-7-83"77 Telephone# o'?-39(j - 0S-0 ci
Type of Building MS CCe 1 t Lot Size sq.ft.
Dwelling-No.of Bedrooms 'j Garbage grinder( )
Other-Type of Building No.of persons Showers(),Cafeteria 0
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Other Fixtures
Design Flow(min.required) VC, gpd Calculated design flow Design flow provided 3-7_gpd
Plan: Date 3- Iq--aoa I Number of sheets I Revision Date
Title 6sp_ Y' )
Description of Soil(s) Fi/\Q S 4 nAd1�/1
Soil EvaluatorForm No. Name of Soil Evaluator
Date of Evaluation g' 5�-,244,�o2
DESCRIPTION OF REPAIRS OR ALTERATIONS new t Vo - Ira, �"� ✓
au) -60$
yleo ct) 60L+ec. c-4 4.42uc1. , a1,c..wbees eQ PI,-,A
.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 lace t system in operation until a Certificate of Compliance has been issued by the Board of Health.
S-7:Signed Date `✓ Is`2oa)
Inspections
NoeZl• 20 FEE
2 1 4• COMMONWEALTH OF MASSAC USETTS r) --z
Board of Health,Yarmouth,MA
CERTIFICATE OF COMPLIANCE _
Description of Work: `Complete System 0 Individual Components
The undersigned hereby certify that the Disposal System;Constructed() Repaired() Upgraded ic) Abandoned 0
by: �ytr (��u
at:10 Welt-ire+ ^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. ,dated . Approved Design Flow (gpd). y a �r�/� �'
Installer: at"b9/}- (z_y�1 s b V tt..T
Designer: 'Po rn 044r►GQ V KS Inspector: M0{�,j t C Z ' 'j Elate: i 1w
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. 0(C IA 1
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herr-joy-granted ranted to; Construct 0 Repair 0 Upgrade XI Abandon() an individual sewage disposal system at
'rat, W e +f4,1 •E- as described in the application for1
Disposal System Construction Permit No. 1-I 22.- ,dated Z 262
Provide :Construction shall be completed within three years of
�the date of this permit.All local conditions must be met. '
Date 412-e-5t► Board of Health /�• f"><+4 4 '