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HomeMy WebLinkAboutApp-Permit-Compliance & As-built NO?) -. -- 1. Fri.5 .eo COMMONWEALTH OF MA SA L�CHUSETTS I )-3 Board of Health, Yarmouth,MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct()Repair g Upgrade()Abandon()-0 Complete System Iq Individual Components Location 4Z W h(3-H.e c LA• Owner's Name i�(ii1�1 0 Map/Parcel# Address 112(A� Wier In, Y,1A,s1r kjrrT Lot# Telephone# 2/5-58w. 0330 Installer's Name gol3„ek,r B.ouf to, T a Designer's Name Address 343 tohi}e.S Pa7{', 5.Yt .„.. l r+ Address Telephone# 5es-6EQ-y ps e 0:1,..imas Telephone# Type of Building ;glen iekI 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 T, /� 2c ,D Date of Evaluation Axe DESCRIPTION OF REPAIRS OR ALTERATIONSZNOC..t. nel d D B-3 �"/` - & c o; I�•ru .The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TI ,�, tt'VE D further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. RG Signed 41,exte,e(rra..•.ne. Date 7-/y'Z3 JuL 13 2023 Inspections HEALTH DEPT. No. FEE COMMONWEALTH OF MASSACHUSETTS C F�A -' r Board of Health, Yarmouth,MA ) �S l Gi d�✓ CERTIFICATE OF COMPLIANCE ©ik_ � Description of Work: 0 Complete System Individual Components 7~ (17... 3 The u e•signed hereby certif that the Sewage Disposal System;Constructed() Repaired g Upgraded() Abandoned ) by: 5.Ott ..rn i . at: L WI►is}/Qr A. has been installed in accords ce with the pr vision 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to 1 application Nqa,—aL,dated / •/s of a., Approved Design Flow par Installer: Designer: — — Inspector Date:_7 61,— , J The issuance of this permit shall not be construed as a guaran at the system will function as designed. I-�S No. FEE COMMONWEALTH OF MASSACHUSETTS C RA k --Vr, r- Board of Health, Yarmouth,MA i A)_ e U Git/ DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct() Repair lc Upgrade() Abandon() an individual sewage disposal system at in W h,i3+1et LAB as described in the application for Disposal System Construction PennitNo. ,dated 7./ . ,a7. Provided: Construction shall be completda-+viuwr+tlu a re/date of this permit.All local conditions must be met. Date 7**a (9`) Board of Health 4:1q,,I► ..,..... — , ) Commonwealth of Massachusetts ,--et Title 5 Official Inspection Form ii. , • --w0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ali• ii, hs 0 ii), wivoti...„ , .1;,....,..., - --_, Property Address Owner Owners Name information isvery required for e .91.. _.._.. _...... ._.. _____. ._._. . .._.. Pgag. ulty/Town State Zip Code Date of Inspection D. System information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, inbluding ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: , Eg hand-sketch in the area below 0 drawing attached separately ________.-____ ______. I , i . _ _ % c...G... .) _ i_ I _ _ _ 1 1 — - .•.14 - T -...„ i JP ,...,,, •, im ---- rte104(._:b 3-3 4)=20 v. _ay 1 r,_ . . i .....„_................ Ei „/. „,,..,..„ \rr,s ,,, , 4 . . . ._ \I .--- , 0 .N, 1: - • 1 'Pvl ,oe.tA5t, 0 ' • \ 4 • • i • , 4,.. • -. , • . - Pi J • . . - 0 ' .• • . - , . • 12..8 I RECEIVED Is ,ifi. JUL 13 2023 X --- lii I 2. z A2'6," HEALTH DEPT. 3 .-.- si '