HomeMy WebLinkAboutApp-Permit-Compliance No. 22 -\L 1 1 �� IV O,v y FEE. �./ v
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
APPLICATION FOR DISPOSAL SY TEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Repair()Upgrade VAbandon()-0 Complete System ndividual Components
Location ,3 /f f Z 6' Owner's Name -�� � � /J7.1e (�
Map/Parcel# Address 5 5' 3 /1 TGr
Lot# Telephone#
Installer's Nam Cts.dC CG c/ Designer Name _
Gi'�i�fG�,CS7 ner
.4, 5 iY Sri oG� 4 .r
Address �_ �lddress ✓ L = V L=D
3J� ��itrr S%•. i� yG<rli
Telephone# rG�7_ 77_5-,,, __5— Telephone#
LEC 1 2 2022
Type of Building Lot Size sq.ft.
Dwelling-No.of Bedrooms Garbage gri lder( J,EALTM DEPT.
Other-Type of Building No.of persons Showers(),CaNerin()
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 %�f�if�� L4�Yi P/ %fie � G� C
/ice _ v
frr 5 or 74" _
.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 '%' i�J�t Date �.Z �
Inspections
No.W ` •2 2 • I \ i, FEE,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Complete System O Individual Components
The undersi d hereby certify that the Sewage Disposal-/System;Constructed() Repaired() Upgraded(Z�Abandoned()
by: ���Gss2 7 ,� ,W 5 T-«
at:
has been installed in accord ce ith the provisions of 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application No. �� dated / -I)-)%.-Approved Design Flow (gpd).
Installer:Designer:( sp ( kd/i.. Inspector: Gs 64Y Date: mac" J
The issuance of this permit shall not be construed as a guars ee that the system will function as designed.
Noe:C C 22 ct � [A IL f ...►i FEE
COMMONWEALTH OF MASSACHUSETTS C
Board of Health, Yarmouth,MA 71-11:1 s e ��t•J/(J
DISPOSAL SYSTEM CONSTRUCTION PERMIT p
Permission is hereby ranted to' c struct() () ()Repair Upgrade Abandon() an individual sewage disposal syste at
, -� �. as described in the m application for
Disposal System Construction Permit No,2-. - 9 ,dated / / .',.
Provided:Construction shall be completed within three years of the date of this permit.All local conditions must be met.
Date 'a `�'0/ iHoard of Health