HomeMy WebLinkAboutDisposal System Application/Documents N .2-4 l�—� FEE lie GO
COMMONWEALTH OF MASSACHUSETTS
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� Board of Health, Yarmouth,MA
c���//// APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT ---
Application for a Permit to Construct()Repair$Upgrade()Abandon()-O Complete System O Individual Components .17 L/
Location 2(A3 pi•/ 5 f Owner's Name W j sr,i 11 e j n ors'Ins 6,4 ri
Map/Parcel# 90 Address 24S /00.1"ST. S. 14(0.4 ,7.
Lot# Telephone#5.08•ZII- ,q,3 cif)V
Installer's Name Abe T •,Owl��� �../ Designer's Name (V/
Address 343 w1'ti 4-e 3 P..7t, , J aAAts`^ ik Address
Telephone# 3o ••s0Q„ yos 8 .'d,.th` iv, Telephone#
Type of Building / J(.S AQ t- Lot Size sq.ft. -5G''J Ijl^
Dwelling—No.of Bedrooms .•�-as 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 EvaluatorForm No. Name of Soil Evaluator ��j� �� Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �G D..Box ra" I 1 ' /.deir-
E.rntnenci-D-. ‘oct.i.: ctce-cnet\-\.
.The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tot not
_t.o placela the system� in operation until
a✓Certificate of Compliance has been issued by the Board of Health.
Signed Keno y tt&X*3,9L%t t Date £'/y-2 y
Inspections
w ; 3or gars „� /40 nee
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f—A
PART CISYSTEM INFORMATION(continued) 1
Property Address: 20 j is)o F_Th \P\? S-c-T.
Owner: {An 10-95otz 6 � - Huts 4-0 µ e
Date of Inspection: 02 jy i 4
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 1 W'(locate where public water supply comes into house)
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revised 9/2/98 10
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