HomeMy WebLinkAboutApp-Permit No. ' 22 'O\02— FEE
t)(_ r' 5' ' COMMONWEALTH OF MASSACHUSETTS JUL 1 4 2022
Board of Health, Yarmouth, MA HEALTH DEPT.
APPLICATION FOR DISPOSALSYSTEM CONSTRUCTIO\ 1 :RMIT
Application for a Permit to Construct()Repair tj<igrade()Abandon()-D Complete System @'Individual Components
Location 146:1 \\)er Le kx, Owner's Name •e *� - pch
Map/Parcel# Address T \ s".'4 �- , \
11121
Lot# Telephone# cribi_54301
Installer's Name '"a
ct
CeN C_Q,.JQn Designer's Name //
Address 'J3O ��.\ ag 1J"w. Address � /
Telephone# :_m_.7�-�>- a b Telephone#
Type of Building 9e-��d{'sl��Q\ _ Lot Size sq.ft.
Dwelling—No.of Bedrooms Garbage grinder( )
Other—Type of Building No.of persons Showers(),Cafeteria()
Other Fixtures
Design Flow(min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -5y .// �i-ei 4..2¢i7 S-Glfiee G lite
-a' /t/ice•i 64,}el<rG474,7 . -7,--'e.. 7'Pe fd .e�C'..r5?c., S e, , c•
.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.
Signed i" / Date �/�/4' 2
,....-
Inspections Inspections
No. '22 2 FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct() Repair() Upgrade(4andon() an individual sewage disposal system at
,/.. .7$ J ' ,- Lenv).6 Gu,, as described in the application for
Disposal System Construction Permit No. 12...iy6 , dated 7s/' ,c 2..
Provided: Construction shall be completed within three years_of the date of this permit. All local conditions must be met.
Date 9-/9•)1. Board of Health , _SCAA-ck------.'