HomeMy WebLinkAboutBHDC-24-103 Nui) .244'tv_,./ FEE
a(-%/0( COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth, MA
°'' ,o\ z APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
E Q�i Application for a Permit to Construct()Repair pgrade()Abandon(')-O Complete System 0 Individual Components
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gv Location �.�5 YC;i1�C,u.7C �L �,��c',�.r' Owner's Name ����', Isn:rt
a Map/Parcel# Address (/Q ke,,-.+ /ki el-
Lot# /3 S - 2 CF 7 Telephone# CI ye 7 o C)
Installer's Name ,�C /224r174 S Designer's Name
60( Address Address 26 1/;1lt:i S FHv&iv,.
Telephone# t 7 j ii, lS t cte lilt_ S:f 44wl N Telephone# 0 1.?I
/19
.ili Type of Building /7 kie Ll Lot Size sq.ft.
I Dwelling-No.of Bedrooms 2- 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
ri'll Plan: Date Number of sheds Revision Datc
4 4 Title
JO Description of Soil(s)40 -
`''M' Soil EvaluatorForm No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS v )(CC((C AS Ivr��t✓/ 'k(. Ze
r .fiy� g IZ ['f'lQ�c' l',fi,<'T Slfr�llzflC�r C't
.The undersigned agrees to instal the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees toyu);to place the s stem ration a til a Certificate of Compliance has been issued by the Board of Health.
I Signed �/e t� .-"&f- 1 Date — ? 2
Inspections
COMMONWEALTH OF MASSACHUSETTS ,
A��Board of Health, Yarmouth, MA //i
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Complete System Xlndividual Components
The undersigned hereby certify that the Sewage Disposal System;Constructed() RepairedM Upgraded() Abandoned()
by: acltr friai f,W.
at: /a f /c-m/knu /f d f
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.071-/-/ ,dated 6-//•„9t-I . Approved Design Flow (gpd).
es � 0).‘DInstaller:
esigneigner: Inspector. Date: 6'-//.-dG)
The issuance of this permit shall not be construed as a ee that the system will function as designed.
COMMONWEALTH OF MASSACI-IUSETTS ,
Board of Health, Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
•
Permission i`4iereby grant d�°; Construct() Repair pgrade() Abandon() an individual sewage disposal system at
to c /am i( nt) 1 i1 as described in the application for
Disposal System Construction Permit No. 62f/. /O'' ,dated 6'// 7 6/ .
• Provided:Construction shall be completed w' c years of the date of this permit.All local conditions must be met.
Date�'/ �'o,t/ Board of Health
. `_.__
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Town of Yarmouth
Subsurface Sewage Disposal System As-Built Information
Street Address: le:72,— /tMp4r7itd /21) r map:er Parcel: '
Owner Name:_____ /IePermit#: gif 1)C- Z‘44-*/0
Date Installed: a/7 724 eV- New: Repair_
Installer Name:_ ZZ Nak-741..1 74 c,f _S-,472eAeek Installer Phone: 5j1(71„4
3 1619
Installation of(list all components, both newly installed and existing to remain in use):
TII �74- ‘‘,644 loey
Leach Capacity(gpd):)350 Ground Water Depth (inches) /49 2:- Health Inspection by:
As-built Diagram
(Print Clearly in Black/Blue Ink and Use Straight Edge)
JUN 14 2024
HEALTH DEPT.
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