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No. DSL ` FEE
COMMONWEALTH Of MASSACHUSETTS
YARMOUTH HEALTH DEPT.
Board of Health, 1146 RCLTTE 28 , MA.
APPLICATION FOP, DISP MM":bWMUC ION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Completl\srtem ❑ Individual Components
Location
3,1
Owner's Name
Vq-,—e7-,4e7T—
Map/Parcel#
80174-
Address
Lot#
Telephone#
Installer's Name
T. ffiE1ZC)V4# %
Designer's Name
1,HbC6 SEMC F-�A!ll
Address
Address
N . J, .
Telephone#
�-,��J�/
Telephone# SSD q—3$S'Z4,&,S
Type of Building �W E��/�[i--- Lot Size1. Z7 sq. ft.
Dwelling - No. of Bedrooms Q-- Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 0 gpd Calculated design flow 444,--7 Design flow provided 44 • -7 gpd
Plan: Date �Q3 Number of sheets Q NG- Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
2 74 6 Name of Soil Evaluator T. _g14AW1147' Date of Evaluation
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 agre to not top ace the m m operation until a Certificate of om aliance has been issued by the Board of Health.
Signed Date
n
iQ
Inspections
No. FEE Of
COMMONWEALTH OF. MASSACHUSETTS,,,
.
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned ( )
by:
at
has been installed in pcco ce with the ovisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. Cf �"/7 ��-dated sj� �% Approved Design Flow -(gpd)
Installer
Designer: J/ J/ Inspector: tl� C/ -Alk Date: 4! 1 clle3
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.1,12 7""_ / r_. ✓E ' t'} �%f!y J�� FEET177
COMMONWEALTH OF MASSA 14USETTS l�'� 7v3
Board of Health, �� , MA.
DISPOSAL SYST CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Y ' Abandon( ) an individual sewage disposal system
at 22- �l?��%//� �� as described in the application for
Disposal System Construction Permit No. `03 , dated
Provided: Construction shall be completed within thr.i� of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date? Board of Health / `�._.�����/L,�✓�L�G�