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No. L/ S:� /
FEE 10
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CO'l MONWEA LTH Of �' ASSAC14USETTSZs A/C
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J.� Board of Health, YARMOUTH HFAI TH DEPT I
V/
j 6�°�4PPLICATION FOR DISPDXY=,W�JIAUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# Z3
Address
Lot#
Telephone#
Installer's Name 0&Designer's
Name
Address AA.. 0
Address
Telephone#
Telephone# C
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Ll Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. requi
Plan: Date D
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow qqo
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ee to t to place the to operation until a Certificate of Complia ce h been issued by the Board of Health.
Signed i 1[ �A �a.s.�-^. CAAA0121e, Date t(�
Inspections
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No. �'/~�.� 7 COMMONWEALT14 OF MASSACHUSETTS FEE V
Board of Health, MA.
CERTIFICAN OF COMPLIANCE
Description of Work: ❑ Individual Component(s) WoLlomplete System
The undersigned hereby ertify t a the Sewage Dis sal System; Constructed ( ), Repaired ( ), Upgraded (Abandonedby:
at A A,
has been installed in accord nce wi e provisions of 10 CMR 15.00 (Title 5) and the � approved design plans/as-built plans relating to
application No; �1.� 7 dated � ! - 0 proved Design Flow �6% 2 pd)
Installer
Designer: I Inspector: Date: .3
The: issuance of this.permit shalll.-not be -construed as a.guarantee. at-the_system-will.£unction-,as-designed----._ — -- - = -
No. / Ssr� G`X�'.�f/. i�i� FEE SO
COMMONWEALTH Of MASS CHUS ETTS
Board of Health, , MA.
DISPOSAL S YSTCONSTRUCTION PERMIT
Permission is hereby g ) Upgrade ( Abandon
ranted to; Construct( ) Repair ( ) an individual sewage disposal system
at i y as described in the application for
Disposal System Construction Permit No. 0- 5,2 Z dated ,)4�
6 40tz •
Provided: Construction shall be completed within th%gFTFrws of the date of this per 't. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date' AA :2 �_®,¢..�oard of Health v