HomeMy WebLinkAboutBHDC-20-00463FEE s a
COMMONWEALTH OF MASSACHUSETTS
Boardof Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) RepairK-Upgrade ( ) Abandon ( ) - ❑ Complete Systemk)Qndividual Components
Location 10 (Do 0,C),irc
Owner's Name (lfl(. D-�n.a� D'
Map/Parcel # S(a 10 f
Address t t o N • �}�, p� �-� 4T-,
Lot # t 0 (
Telephone #
Installer's Name �o 10,L -1 C. ,
Designer's Name 13 o E2
Address 3 3 1..�� . tG l jp/g-i���
Address
--Telephone #
Telephone #
Type of Building (vnc�s.i M �@� h4+►,i �t-+� r _ Lot Size 4 • Z t- �j� sq. ft.
Dwelling - No. of Bedrooms 0 Garbage grinder ( }
Other -- Type of Building
No. of persons Showers (), Cafeteria ()
Other Fixtures
Design Flow (min. required) 1 %9 0 gpd Calculated design flow & Design flow provided 10 gpd
Plan: Date Number of sheets Revision Date -Z - 7,v g Zg - Zo
Title �- �ic7v1.•o► 1Ci C
Description of Soil(s)
Soil Evaluator Form No.
e, P Loy- r7o r.
Name of Soil Evaluator AAvt Pl c-%J Date of Evaluation t I t-k ` "2a
DESCRIPTION OF REPAIRS OR ALTERATIONS S � c rjA't- 14--Zo S e - !!2 E 49�k
T' o r1r►� �L., [/.4t o-f To i � � r _ g o IL. % &-, e j a L' Q-k J-1 to F
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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed -t""Date " 2, 7 2-1:-
Inspections
COMMONWEALTH OF MASSACHUSETTS�-
BoardofHealth, Yarmouth, MAC
CERTIFICATE OF COMPLIANCE 3
Description of Work: ❑ Complete System Individual Components
The undersigned hereby certify that the Sewage Disposal System; Constructed () Repaired () Upgraded () Abandoned { )
by:
at:
has been installed, in accQrdance with the provisions f 310 CMR 15.00 (Title 5) and the a pro ed design plans/as-built plans relating to
application No. dated 0 . Approved Design Flow U . y (gpd).
Installer: _
Designer: Inspector: Date:
The issuance of this permit stall not be construed as a guarantee that the system will function as designed.
• rill 1,.R � � �
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permi � i�O>oher��e to; Construct
Disposal System Construction Permit No.
-- ---- FEE
an an individual sewage disposal system at
___ as described in the application for
Provided: Co struction shall be completed within th e years the date of this permit. All local conditions must be met.
Date �� _Board of Health
3
0
0
TI
x
O
v
CD
co
O
n�
n
3
cr
0
cr
m
c�
is
0
S
CD
m
0
Cp
0
0
C'
cn m
S
0 n
= 0
a ch
m
.� CL
0
S d
< N
(D
C C1
a C
C CD
CD
cr
bt
CZ)
O
CD
C
C n
(D
CD 0.
m
Q
O
m
0
3
0
00
CD
0
N
CD
a
0
D
0
CD
m
m
0
0
0
CD
7
S
N
-+
3
CND
Al
O
0
3
N
C
Q
m
W
El
N
w
N
p
00
m
o
W
�
N
Q
�
El
n
O
c
Oi
c
(n
c
CD
(D
m
3
El L
0
N a;
�
T
0
p
CD
c
N o
n
C1 0
CD
=.
0
V
cn
0
❑
a
m
0
CD
CD
D
a
3
C
cn
0
S
N
3
0
S
D
N
v
co
In
c
CD
v
_
3
t_
N
c
im
OD
!
S
=
SN
CD
' �
N
0
N
CD
r
w
N
m
m
0
�
3
R
m
x
O
N
D
m
z
z
v
cn
T
G
0
C
D
`U)
N
0
I3
2
D
m
w
(DCL
r
m
m
x
CD
w
CA
z
CD
x
a
W
O
2
rm
m
U)
0
c
Err
CS W
O N
c
03�
°° 9 -a
OD D
0 CD
�oX
(0 -4 0
C) V a)
0 N d