HomeMy WebLinkAboutBHDC-24-128 No. FEE 55.00
COMMONWEALTH OF MASSACHUSETTS
I�� Board of Health, Yarmouth,MAr,_ ()
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair OUpgrade Abandon -❑Complete System tel ndividual (u
Components
t a IV
Location 17 5 5 15 .rLt1 Den 1 J Ya..4%o r m C�
(� /1 Owner's Name �) 2INA-
Map/Parcel# 2 3 - q Address 175 s r1 fler t. ,5.VArmAdks
Lot# Telephone#SOEr.77/.t•$7
Installer's Name 4 6eir+b�..��� , r�� Designer's Name •
Address3G3 ( .1; c.7 fain ,s.yQ{MOv�6• Address
Telephone#,SOs 5.4- YQ,S 8 g41.5,441, Telephone#
Type of Building 1`GJV elertri a' 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 Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ge.piaie y I,f ( -r-n504. New:5e Tv
Cz6SPool
.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 Aber �i& t JII Y Date 7-VI-Z y
Inspections
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) r b
SKETCH OF SEWAGE DISPOSAL SYSTEM:
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Include ties to atleast two permanent references,landmarks or benchmarks.
Locate all wells within 100 Feet.
- C (_(jsa j:
a
:44.
till
c p, \ .37 r i. as/
0
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1
JUL 2 :" 7UZ4 ,
DEPTH TO GROUNDWATER: # e, /J i45 /}.�1
Depth to groundwater: fi/6 Feet i pp 0Eu.�ft-o1� 7
'
Method of Determinatign or Approxr1m�tion: Au/ems G /+'O J 7`D /D d ''
14/0/✓' p/1 E71"1,ea'
-7-
Town of Yarmouth
Subsurface Sewage Disposal System As-Built Information
f 75 .S PC i e_e -C' 1 Ma �2'3 Parcel: q
Street Address: '� - P�
Owner Name: b e.Cti i S Vac-bon Permit#: SON- 2 - /28
Date Installed: 7 3 O"' 211
New: Repair:
Installer Name: i V +3, ovt ( • .+-1( Installer Phone:Et' '5C, '/06 3 $,1i
Installation of(list all components, both newly installed and existing to remain in use):
J i .,IP.,11 :) `, : new It " 6e-k eh? Pi Pe- ? , til-i o Le53i0 r7 ,)
Leach Capacity(gpd): Ground Water Depth (Inches): Health Inspection by:
As-built Diagram
(Print Clearly in Black/Blue Ink and Use Straight Edge)
A
175
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AUL; 0 5 2024 •
'02 HEALTH DEPT.
A B C D E F G
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