HomeMy WebLinkAboutApp-Permit-Compliance No.W` \J/C 2 1. 1 FEE 53 gagmo V L_LJ
! COMMONWEALTH OF MASSACHUSETTS a ( -�
Board of Health, Yarmouth,MA MAY 17 2021
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM=T HEALTH DEPT.
Application for a Permit to Construct()Repair Upgrade()Abandon()-l7 Complete System O Individual Components
Location el Li xv(r./.tve Ave, Owner's Name{tyai e WO)LLc
Map/Parcel# Address II, K 1is tAkt, h faMl;
Lot# Telephone# .t7'—577- !72 Cd6
Installer's Name FV�r .$a £io( ('a o r�, Designer's Name c7
Address3, 63.4.0 pip AN s t y�-MTV Address
Telephone# Jt�E $eql- '1n50 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 re pt(fie./4C-.`n !f J/1 t� jm— C,r'P;pe. eptA e_
P® iSe TV 'n Ier 1 5q ri - Tart Rts-cite
.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�t/oplplace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 13 1 IIn"^ �filar3 i EVv(F�, t Date a-1 r'
Inspections
No. a 1 1 17 FEE J�
u COMMONWEALTH OF MASSACHUSETTS l�
s e?
v� Board of Health, Yarmouth,MA (� L/.V
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CERTIFICATE OF COMPLIANCE p
J
Description of Work: El Complete System 0 Individual Components
The undersigned hereby certify that the Sewage Disposal System;Constructed() Repaired Of Upgraded() Abandoned()
by: %fur.3 our le
at: yy-gL214,4, ',pe A
has been installed in accordap/.e with the provisions f 10 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application o. s f`t 1 ,dated . Approved Design Flow '• (gpd).
Installer: P S �•Golve,r r' g,0-tx _MC..
Designer: Inspector: t''' Date: '
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Nogg ct. 2\• 93—e 1 FEE 5
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct() Repair i 4 Upgrade() Abandon() an individual sewage disposal system at
/pN-L y t✓04,1‘ve A'Ve as described in the application for
Disposal System Construction PermitNo.d I—I i7 ,dated
Provided:Construction shall be completed within three years of the date of this pennit.All local conditions must be met.
Date 6Jaei/�1 Board of Health a d".AA-.