HomeMy WebLinkAboutApp-Permit-Compliance i L-i7172-2-I —00SS1n1-1
No.W‘AW_,*Z I '21 D2- FEE -5g?±°'``D
Z 1 , 0 SD COMMONWEALTH OF MASSACHUSETTS
Board of Health,Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Repair VUpgrade()Abandon()-OleorMplete System l individual Components
Location-1 a { 3 Owners Name
Map/Parcel# Address
Lot# Telephone#
Installers Name OjfA 4 (ans-r(.ci-(Oh Designer's Name (3,Sc 6-(bop
Address Po sox a(o .5-.Penn i_5 Address 3Ga Moir S4-litrotcv.kh W_, �_- __ _ _ : 1
Telephone# co'- L 3'vt 1 6 3 , Telephone# SO S- '7-S- ( Gi i
Type of Building (O \lYA-T i \ct\` Lot Size N.ft. MAR 0 1 2021
Dwelling—No.of Bedrooms Garbage grinder( )
Other—Type of Building 32 (-Ioie rn.n. 9olti. Ca.-'se No.of persons Showers(),Cafeteria() HEALTH DEPT,
Other Fixtures
Design Flow(min.required) 1' C'O gpd Calculated design flow Design flow pr ided gpd
Plan: Date ' /' b/21 Number of sheets ( Revision Date e� 30 2
Title /�/e[/Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 1
DESCRIPTION OF REPAIRS OR ALTERATIONS MIL)QU) (SO 0 G-Qa. Ijt 4 i111,L IT CX ighi•t 7
Cam -l-rne.�t k J- - `3bOO yak EAc J
CompAr►mer4- 01 - t t Cso 050.1
.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 '��� Date of/d b/a
Inspections ,
No. `2.1• Z1 0 2 FEE , 1 \D
COMMONWEALTH OF MASSACHUSETTS i r 1
Board of Health,Yarmouth MA •�/ jrr . _
CERTIFICATE OF COMPLIANCE
Description of Work: omplete System Individual Components 'BOX r SET" lO'�11 T't)M.P
The unde igned herebycertify that the S wa e Disposal System;Constructed() RepairedUpgraded() Abandoned()
by: VI01 i4 Ot‘.S-INt,C-\-1Or%
at: '1 N'd (Z - 'd�%
has been installed} with the pro •i of 310 CMR 15.00(Title 5)and the a roved design plans/as-built plans relating to
application No. LL,,II ��jj VV ,dated ; 1 I . Approved Design Flow _(gpd).
Installer:Designer: 1,S 6 r,.0 Inspector: '`/�
r,.;b�G\C o p Date: L2
The issuance of this permit"shall not
be construed as a guarantee that the system will function as designed.
No. •2.1 `t O L. FEE____
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct() Repair Upgrade() Abandon ) an individual sewage disposal system at
'a / as described in the application for
Disposal System Construction Permit No. Zt- 0� ,dated 3'/ 1 Zd�
Provided.Cons ction shall be completed within thr-, years• •• e of this permit.All local conditions must be met.
Date 3 24 I Board of Health %A11111k A..—'u