HomeMy WebLinkAboutApp-Permit No,t m.a,' ZV ` C _FEE �-�
21 14-8 COMMONWEALTH OF MASSACHUSETTS
JUN 17 2021
Board of Health, Yarmouth, MA
DEPT.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct()Repair KUpgrade()Abandon()-0 Complete System'lIndividual Components
Location 1t CA,M?Iutil J .b. Owner's Name Ti'.i,S- ,Ne C/ki'E CEO 4-awtc.3
Map/Parcel# t S I ( 2(o Address 4 3 t,.w,90y{ IRi . S�11 F v 0,3114
Lot# Telephone#
Installer's Name NAcy2� Q o.R Co. Designer's Name
Address 3(4,'3 u6„}.t5 ?Am Soapi yAavt4tuTH Address
Telephone# 5-02 - - l'1 - $ Ti Telephone#
Type of Building _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 EvaluatorForm No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
VSliki 1 ACLJ b 13 3 N 2-0 13‘x AID
.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.
SignedN".(:),v,CDate (e)
Inspections
No. u. Z, 96 FEE
COMMONWEALTH[ OF MASSACHUSETTS 1\l c P
Board of Health, Yarmouth, MA C*-
DISPOSAL SYSTEM CONSTRUCTION PERMIT el isydvi
Permission is hereby granted to; Construct() Repair Upgrade( ) Abandon( ) an individual sewage disposal system at
U. C AAkPt bL t _ as described in the application for
Disposal System Construction Permit No. Z( - 14 e, , dated 4, (z
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date 4:1 2S02Ci2 i Board of Health 1^-b P — A )