HomeMy WebLinkAboutBHDC-24-201No.
IWAVC - UA - Za 1
COMMONWEALTH OF MASSACHUSETTS
FEE
?A% 1V F� ON ti A._c Boardof Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Otr ar3 Application for a Permit to Construct air )Upgrade() Abandon O Complete S stem Individual Components
Pp �eP () P� (} ()- P Y � P
Location 30
}t o+QS C WA4
Owner's Name
BAN N ' ^%CaLf=(L
Map/Parcel #
51 22 .
Address 'Po
t)D)( 13f3 j %jA4_hl1)JCFf i Mjq DUY
Lot #
Telephone #
Installer's Name
1 coo-,n -AccXDQ c_
Designer's Name s �1Zv
Address IC)
� '24SOM16 RIP
M41
Address 10
q 0 1 Q-0 % UH NA
Telephone #
6o Q.
Telephone #
505. 152-11% 310,00
Type of Building 51 N (44— �1� l j Ifi��TlJ�� Lot Size lbo r sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons _� Showers (1), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 D gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets ? Revision Date
Title S1[�cstinl�1�R1.Q�
Description of Soil(s) L-O ttwy s_kt l O -to %A frnmw %N fl
Soil EvaluatorForm No. Name of Soil Evaluator fAA SVQ9,,, Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
* TV_rN Ckt pelt- — +fit aT 2 K-16k - VA, IV / -Ptlr 2o2 t( ylot V g —
The unde a t ' stall t above descri iv' al Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to not t in operatio until a ertificate of Comp nce has been issued by the Board of Health.
Signed Date 3 li� .2 RE%EP"w"'
Inspections
I 2
HEA11-4 o=�•
--- a_____-____________________-_________________-___________________-___________________________
a FEE
COMMONWEALTH OF MASSACHUSETTS 42
Boardof Health, Yarmouth, MA 1->.
1
CERTIFICATE OF COMPLIANCE
Description of Work: O Complete System CLJedividual Components
The }�nddersigned hereby certify that the Sewage Disposal System; Constructed O Repaired (.4-Upgraded O Abandoned ( )
by: SQL-` /,4"
at: ',-J
has been installed in adcordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. nip/-'�t -,dated 11 Approved Design Flow 'i;3 t) (gpd).
Installer: e&
Designer: F_ AS S..rvtM Inspector: Date: ^
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. t - o
COMMONWEALTH OF MASSACHUSETTS
Boardof Health, Yarmouth, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct O Repair t,4pgrade O Abandon O an individual sewage disposal system at
�. as described in the application for
Disposal System Con ruction Permit No.,?c/ at'� _ dated // at -9 -t
Provided: Co struction shall be completed �
Date / Board of Health �7
of the date of this permit. All local conditions must be met.
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