HomeMy WebLinkAboutApp-Permit-Compliance No. V -. 23 -2103 FEE SS.O
COMMONWEALTH OF MASSACHUSETTS
5/ Board of Health, Yarmouth,MA
37 r� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Repair$Upgrade()Abandon()-0 Complete System Klndividual Components
Location INnunTn Dore Al. Owner's Name saber*{' 41.e *e $j
Map/Parcel# Address H4 1 r Dere ed.
Lot# Telephone# 781-72'1- Z157
Installer's Name fo T ii.v�eO.rev. Designer's Name
Address a+ Address
Telephone# 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 n Date of Evaluation
/mo
DESCRIPTION OF REPAIRS OR ALTERATIONS o we, Alai
lai n t%�- �+s I�€ 6 C
t-k 4Se 7-0A €l-6.S47�"�''r 7i4 ri K.
3s11, Gelifo sob are Xrs seed.c -rror-teessnplart.
.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.RECEIVED
Signed rilL��OO & �,pva ea=�. Date 7 z' RG V G Y
JUL 2 4 2023
Inspections
HEALTH DEPT.
NOj C '2Z -212—q FEE
COMMONWEALTH OF MASSACHUSETTS /..-_.
Board of Health, Yarmouth,MA
CERTIFICATE OF COMPLIANCE b
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Description of Work: 0 Complete System"Individual Components ,
The u ersigned hereby certify that the Sewage Disposal System;Constructed() Repaired/4 Upgraded() Abandoned O
by: Hifi a Our CO.j
at: 14 rat.;^ be rG
has been instal ed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
applicatioR No.- —�dated . Approved Design Flow (gpd).
Installer: Cullal Ic, u„r
Designer: 9 V Inspector: Date: 'd j—0 ]�1_
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Now IT-J3 ' Z9 FEES
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;�nstruct() Repair(4—Upgrade() Abandon() an individual sewage disposal system at
44 (�..n byre •KO described in the application for
?
Disposal SystemConstruction Permit No.0 - /3 ated ) .
Provided:Construction shall be comple ithin s of the date of this permit.All local conditions must be met.
Date a-7 go?) Board of Healtl
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