HomeMy WebLinkAbout4840 915 West Yarmouth Rd BOH Disposal System Construction Permit 04-220 No. O4.Z O 7 Li— e.1(r' b &, d U'vs /i j / FEE ' !/lJ
o / 7 COMMONWEALTH OF MASSACHUSETTS ( 0 i/V/
YARMOUTh HEALTH CUT.
ao k %e l C is�bs- -� Board of Health, 114C ROUTE 28
�I'LICATION FOR DISPOS R�� JCTION PERMIT
' /� 7nOl.� toeZtucc�
Application for a Permit``,/I to ons�trPuct( ) Rye�pa�ir( ) Upgrade(Sdf Abandon( ) - C�Complete System ❑Individual Components
Location q/5 WSJ/ Y/41 MOt 171 i . ( Owner's Name l., y 6TZP$TRI <
Map/Parcel# App115 {XGEL f 6, Address SAME_
Lot# Telephone#.370O-36a_ 69/J//)
Installer's Name poi dow ioci )t? '/4/C Designer's Name a/E -5e /t&I6 mod/ C
Address 3N I�IDKUI�t 1\l/l.h f , J J/J1S Addressgs-S m.-Wf �i RD S.Lu4 /f 5
Telephone# (.5.68-,s�S-.993 Telephoneµ#+C1'rl�li/t,398. /a�
Type of Building 51Di �'� - E y� .ft.
Dwelling-No.of Bedrooms lP /MF i i'dla G7› /' Garbage grinder( )
Other-Type of Building o.of persons Showers( ),Cafeteria(-)—
Other Fixtures nn'' / ,j�/
Design Flow(min..r/e uired) �6 V gpd Calculated design flow Design flow provided (/ -7 7 gpd
Plan: Date 4,a 9/Q / Number of sheets / Revision Date
Title
Description of Soil(s) La/my SA1D NG) �D
Soil Evaluator Form No. Name of Soil Evaluator rt./cr Date of Evaluation /0-2, 0 1/
DESCRIPTION OF REPAIRS OR ALTERATIONS SEE PL//
The undersigned agre to install th ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ce em in operation until a Cet te,ot�Cppt�ljpgoe has been issued by the Board of Health.
4:1Signed
rA lllllnn�/ Lt �U`-
Inspections .74t9i g'GLA id.-
No. 04`.Zle i`D. GU
COMMONWEALTHMASSACIIUSETTS ,_..� FEE y
Board of Health, y17RM0 6417771 ,MA. y
CERTIFICATE OF COMPLIANCE N�f,�
v
Description of Work: ❑Individual Component(s) ld'Complete System
The undersigned hereby certify that the Sewage�Diisposal System; Constructed( ),Repaired( ),Upgraded ,Abandoned( )
by: P at /\1� C5W//tt ) J+'V(�
•ci1�j izoF..ST yf 3A o L/1 T1-1 /C'Qt9(7
has been installed in ccorr�d/aan'ce with the rolvlision o s 310 CMR 15.00(Title 5)and the/p.p r ved design plans/as-built plans relating to
application No. � rV , dated 6-< . Approved Design Flow �d• pd)
Installer >�/S1)) (1.0 N/ t J Ud�s/ /A/C.,
Designer: 3lIFFTS1 tN6. Inspector: Date: 01/09
The issuance of this permit shall not be construed as a guarantee that the system will ction as designed.
No. 04 _-)-0 P/ 7)7 FEE 5-.//i/
COMMONWEALTH OF MASSACHUSETTS ,JI ' /
Board of Health, *Ai U 14T 1 MA.
•. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(/) Repair( ) Upgrade t() Abandon( )an individual sewage disposal system
at qic (,(1 r ViKinOIA/!7 ///?1)- as described in the application for
Disposal System Construction Permit No. O 1' ,dated 4-2 I.
Provided: Construction shall be completed within`thrree ye u o the date of this permit. l local /onnd�itions prust be met.
Form 1255 Rev.5196 A.M.Sulkin Co.Boston,MA Date r7'1 ) Board of Health O�`'r d/ice
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