HomeMy WebLinkAboutApp-Permit-Compliance No. DIC.,' 22. = l Cli FEE
5 f o 13 COMMONWEALTH OF MASSACHUSETTS
2' Board of Health, Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Repair O Ab Upgrade( andon()-0 Complete System g'Individual Components
Location 9 (4-T G„,e_.:. Owner's Name, fO . ,4 r€A.7 i ero1
Map/Parcel# Address ��...s. .�
Lot# Telephone# 6'«'-8O 3 - 25-7/
Installer's Name Designer's Name
Address 3Sb.......reeGiK ,ST u/_ t"� w�j µ,t Address
Telephone# c2A-' 7-pr...7-pr... 2 7.zs-- Telephone#
Type of Building 5 i / _ ,i---4. e% 3 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/awe/ /f/e.— c— 5)e G,S�.P, f'/ti..,-.7 -e..---i l
76V/�7E I K SSS�� J42 E k,`Sfr,r9P' .S',--.... ,'. s j - r--r.
.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 Date6:4 ��� _(� �022
Inspections
—HEALTH DEPT.
No.a- Y�• LZ ' OR tPci FEE ..- .�
t t r h-�T 5 a[ COMMONWEALTH OF MASSACHUSETTS l `/- � .3
f l I e T usl'C Board of Health,Yarmouth,MA c
i f -
--rcy5 .ttt-. TA CERTIFICATE OF COMPLIANCE D '1 •9
Description of Work: 0 Complete System 0 Individual Components - '- .2.3
The undersigned hereby certify that the Sewage Disposal System;Constructed() Repaired() Upgraded() Abandoned()
by:
at: 9 co ....Y- L_.7
has been installed m accordance with the provisions of 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application No. -' 0/ ated 19--41 -��Approved Design Flow .— gpd).
, Installer:
Designer: j - Inspector: Date:
, The issuance of this
,permit shall not be construed as a guarantee that the system will function as designed.
• No. ssan
\ft.�-.22-.V9(Q9 FEE 5' Gc/=
("c rr( YAA COMMONWEALTH OF MASSACHUSETTS — c "��'
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N�� t"6Board of Health, Yarmouth,MA c�
'T 5�ifi7 c*CA v- - DISPOSAL SYSTEM CONSTRUCTION PERMIT -
Pe ' 'onthereb gra ted t9; Construct() Repair() Upgrade() Abandon() an individual sewage disposal system at
Q ` L..,,°J as described in the application for�•f
Disp al System onstruction Permit No. — ,dated /; ._3
Provided:Construction shall be completed afithin-i e y of the date of this permit.All local conditions must be met. ; „ a 3 �1'2
Date I` )a" 13 Board of Health c�4.11 Ca"-�
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