HomeMy WebLinkAboutBHDC-24-113 No. ' 11 ' FEE
COMMONWEALTH OF MASSACHUSETTS
V (((/ .,. /2/ Board of Health, Yarmouth,MA
(� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construc'Repair()Upgrade()Abandon()-❑Complete System ynndividual Components
Location JQ ii- /s.e �Un d Owner's Name ,c:/em Arqj rt, Pot,kiS
Map/Parcel# 4' — V Lp Address /4 4.),,_,,_ an AQ f
Lot# Telephone# sj)$-- 7'7 /-7 17-
Installer's Name K EeAview/ Designer's Name ' �d
v�q rho X .
Address y1 K.; -�- IA c19,n 1�1 Address
Telephonnec## 4--ei ' t f 5, "7 r c' Telephone# I
Type of Building t/w'tiI/iii 9 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 D' '-�CJic rP pI6 [Q KY?7-411
.The un rsi ned agrees to install the a ve ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ag o o place the sy Aeration until a Certificate of Com liance has been issued by the Board of Health.
Signed Date e(
Inspections
^ 04.
No. FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA 45 4;
//
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Complete System Individual Components
The un rsignyed hereby certify that the Sewage Disposal System;Constructed() ()Repaired to*Upgraded Abandoned()
by: Ql Gee,V4"11
at: / Horse Po (24
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.,t/•/a/ ,dated 7. 5.,)9i . A r sign Flow ti A (gpd).
Installer: Sp,..,k rvi a r
Designer: "jA Inspector: Date:
The issuance of this permit shall not be cons as a ee that the system will function as designed.
FEE
V' / ) I 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
f ri L/u.r' c Oo"c11 d as described in the application for
Disposal SystemConstruction Permit No.dc/. i J j ,dated 7 e'y.)Li
Provided:Construction shall be completed ee years of the date of this permit.All local conditions must be met.
Date- -d Li Board of Health e''L C -
Town of Yarmouth
Subsurface Sewage Disposal System As-Built Information
Street Address: 19 -Poise ov c 12oQa) Map: 46 Parcel: 46
Owner Name: 1a;j o.n Art;vo po u IoS Permit#: 3L DT-
Date Installed: -4- Ig- 2,02.4 New: Repair: I
Installer Name: S ea(Cvvio.vk Xtavw-101 Installer Phone: 5O$- 432- 5565
Installation
of(list all components, both newly installed and existing to remain in use):
4 ipv‘ Bc
Leach Capacity(gpd): Ground Water Depth (inches): Health Inspection by:
I certify that this system has nnstalled ' accordance with the provisions of 310 CMR 15.00 and all local
regulations. / l
Installer Signature
As-built Diagram
(Print Clearly in Black/Blue Ink and Use Straight Edge-Label Risers and Zabel Filter)
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