HomeMy WebLinkAboutApp-Permit-Compliance Nb\-tC-Z 1 10 FEE
c j/D COMMONWEALTH OF MASSACHUSETTS
���':/ Board of Health, Yarmouth, MA
„ee (pt�' ,� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Pmit to Construct()Repairpgrade O Abandon()-❑Complete System❑Individual Component/Location 1.)-5 KC, l r,{,t.',c A ,..)V :.� Owner's Name �271161 &tit /r
Map/Parcel# Address ("�o �� tl J f /jr
Lot# / 3 - 7 Telephone# J`S" y 7 ifo Cl
Installer's Name '5' Designer's Name
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/V( Address
C (��n�GYCt1 Address �.lire , s f l-fraagr��L >
Telephone# i IV_, t I�- c k)vil Telephone# 01'7-
/..--li Type of Building / --al tC 1 Lot Size sq.ft.
f54 Dwelling-No.of Bedrooms `2/ Garbage grinder( )
Other-Typc 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 0 .h`-�id(a-c _ ;[/(S/fit/�L,I7ekt /�6Z
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.The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to plst ration u�tll a Certificate of Compliance has been issued by the Board of Health.
i Signed2? 4A / �� Date (!i _ — Z40 Z-V
Inspections
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COMMONWEALTH OF MASSACHUSETTS
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Board of Health, Yarmouth, iIAA
CERTIFICATE OF COMPLIANCE
Description of Work: :I Complete System IB.indlvidual Components
The undersigned hereby certify that the Sewage� Disposal System;Constructed() Repaired Upgraded() Abandoned()
T by: /v/4r •hS
at 'a f AA,Aet(Li rl r
has been installed in accordance with the provisions of 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application No.0`/-/ ,dated 6 -/t'^a y . Approved Design Flow (gpd).
Installer: �ci t),,5
Designer: Inspector: Date: 6-//�?�I
The issuance of this permit shall not be construed as a ee that the system will function as designed.
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No -'-------'— ---------___.___-_•_-'_----FEE__ter` 57—s— 4• �O
COMMONWEALTH OF MASSACHUSETTS
Board of Health,Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission
sn is,{tereby grant d 1st (); Construct Repair pgrade() Abandon() an individual sewage disposal system at
CM 4t1U p tl as described in the application for
Disposal System ConstiuctionPertnitNo. t2t/. /O ,dated 6'//•G7 L/ •
Provided:i! Construction shall be completed w�• •c years of the date of this permit.All local conditions must be met.
Date b-/ ' '7 Board of Health