HomeMy WebLinkAboutApp-Permit-Compliance9 7`/96 1146 ROUTE 28 FEE $50.00
No. 80. YARMOUTH, MA 02664
COMMONWEALTH OF MASSAC14USETTS
v
Board of Health, Yarmouth �T , MA. "1
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(,J Upgrade( ) Abandon() - ❑ Complete System $Individual Components
Location 108
Quarter Master Row
Owner's Name Frank Chamberland
Map/Parcel#
0
Address 108 Quarter Master Row
Lot#
T C-1-5
Telephone# 394-7602
Installer's Name
Wm E Robinson Sr S t Sry
Designer's Name
Address
p O Box 1089 Centerville
Address
Po Box 1044., S Dennis
Telephone#
775-8776
Telephone# 398-8311
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder fib
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) -310 gpd Calculated design flow —a -31D Design flow provided 33 -2--- 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 Title 5 Leaching according to the plans
(job #12-731), of C R Short Five H-20 infiltrators.
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 ace ie system operation until a Certificate of Compliance has been issued by the Board of Health.
Signed W L� Date
Jnspections
No. COMMONWEALTH Of MASSAC14USETTS
FEE$50.0(0,
U
Chamberland
Board of Health, Yarmouth meq. � �;
CERTIFICATE Of COMPLIANCE
Description of Work: EUPdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (X), Upgraded ( ), Abandoned ( )
by: Wm E Robinson Sr Spet Sry
at 108 Quarter. Master Rowq
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. 9 7-/9'G� , dated 6 `., 7" y' 7 Approved Design Flow --3 3 2—(gpd)
Installer Wm E RobinsonnSr Sept Srb fir/ �
Designer: C R Short Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.