HomeMy WebLinkAboutBHDC-24-83 No.NDC FEE 55 , 190 ;
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA bt
rat
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PER T gy`(N�\ N )EP�
Application for a Permit to Construct()Repairj ()pgrade()Abandon -El Complete System'�f Individual Components
Location se pc
f; Owner's Name( iftis, ',to It( G`�,sph hf}Me
Map/Parcel# S_0 //9g Address S$ L. yus Pe br
Lot# Telephone#so'g",.3g8•• ZI2/
Installer's Name 1`r"A"c+ etx-t, -. Designer's Name
Address 3b3 Loh;+es paw 3, yotrytevit. Address
Telephone#Sag 5o9--yo58 Ri 5j4in% 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 Evaluator Form No. Name of Soil Eval F 1 uator p Date offEvaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS tepL( L11' Pe J- 0V{o µ 1 J,de o4 bo,i d i'r9
°;t) of Sfl' TAAK.
.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
, �eA t
the system in operation until a Certificate of Compliance has
been issued by the Board of Health.
Signed J tQ� ►T/ � DVS LC/. Date $^//
7— 2 7
Inspections
No FEE 5 , ov
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION� PERMIT
Application for a Permit to Construct()Repair�pgrade()Abandon()-D Complete System'�Individual Components
Location,5B Leil pofjDf; Owner's Name C,K4pato,6 tole,64,46/eAsor, Gaza kwwe
Map/Parcel# c7(7 //9 g Address S 8 Lortif p b c.
Lot# Telephone#Sot3g- 212I
Installer's Namegokocc-+ Z. our-�J�. .;�►�" Designer's Name
Address3b3 whites Po--6,. 3 e jftl�v/ Address
Telephone#3.08 5o4.-#059 3t bt 5,+ 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 Evaluator Form No. Name of Soil Evaluator Date
-ofEvaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS A f I p tr. 1-1 'e- �' e M QV 1 5►de o4 bV k)a(tn9
i t11e4-.etc SY TA i .
.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
essystem in operation(yi untiln a
Certificate of Compliance has been issued by the Board of Health.
SignedZt 4 /abbe i, O Th. itn Date $./y" 27
Inspections
No. FEE
COMMONWEALTH OF MASSACHUSETTS /� ( /7Iy'
Board of Health,Yarmouth,MA �`7
CERTIFICATE OF COMPLIANCE
Description of Work: l7 Complete System Individual Components /
The undersigned hereby certify that the Sewage Disposal System;Constructed() Repaired(Upgraded() Abandoned()
by: loi,gr-t"A.et;r .Znc
at: 3T �has been stale m a cor ce � the provisions of 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application .� bi ,dated 5 t/. . Approved Design Flow (gpd).
Installer: jb.g/.L.
Designer: . . 0, Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Pennislion,is a gr system at
to; Construct() Repair Upgrade() Abandon() an individual sewage disposal syste at
Se 1.0,04ftvo ,bC. nn •
as described in the application for
Disposal SystemConstruction Permit No.O' ' • • ,dated 5-• v. / .
Provided:Construction shall be completed wit ' years of the date of this permit.All local conditions must be met.
Date S•'''1`J41 Board of Health
D-BOX O LINER PAIR
ADDRESS: _0(3 \ [`1
INSTALLER: 1 V cuA.
NEW OR 'EPAIR•
DATE:
2� 22�
TIME:
NOTES: •
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Town of Yarmouth
Subsurface Sewage Disposal System As-Built Information
Street Address: S 8 LonA Pood Dv, Map: SO Parcel: PI
Owner Name: 6hapit4e/i\1iole 0.AA Kie4.60A f'oetefa I name Permit#:
Date Installed: - 26-2.1.7vi New: Repair: )(
Installer Name: rob„,, Lia Installer Phone: 508-50 700
Installation of(list ail components, both newly installed and existing to remain in use):
t\e.tA) 3e-k ‘-lo pv6 P;pe coy\-\ ao+,6)`de 194- +6 Loe) 4.,(or)
TO ;M + q4. (5ep vit. K
Leach Capacity(gpd): GroundfWater Depth (inches): Health Inspection by:
As-built Diagram
(Print Clearly in Black/Blue Ink and Use Straight Edgc)
R ea-f-
I
2,5 me
I-01)ra% 0 2- pot, 3
JUL 0 3 2074
6er7r\Fç
0 HEALTH
A
1 /21
2 25'4" 13'
3
4
5
6 •