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No. ,Q�s / FEE
S�Aej O MONWEAILT14 Of MASSACHUSETTS
YARMOUTH HEALT EP
�'� Board of Health, , � T
1146 ROUTE 28
APPLICATION FOP DISPOSALs0YfflWuC�Oil*TWdf4TION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade/Abandon/-Complete System U Individual Components
Location 3 AW
PJ Z S Yl'!®
Owner's NameMAC—ED
U
Map/Parcel#
Address J TA -i- i ' J, H ✓rnou-r&
Lot# 77/1/3
Telephone#
Installer's Name''
C ? S all
Designer's Name
Address s C, ellrelc
V///,
Address P 0. 330 71 M
Telephone#
Telephone# —7-7S b(�
Type of Building•�I Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder (k)b
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow :3:0 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
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 r77ainy, ' _� %1, Date
Inspections
1____71No.. / O FEE
COMMONWEALTH OF MASSAC14USETTS � 7
Board of Health, )1BLJL a (Mlt MA.
CERTIFICATE Of COMPLIANCE
Description of Work: U Individual Component(s) 2<omplete System
The undersigned
hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade�,�, Abandoned
by:
at 3 FA-wA.l Q,) AJ yAvYle
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 NoO/`� �, ddated2 Approved Design Flow(gpd)
Installer /�� �f11 j%% t_ A
Designer: F--- .__3 • ( ;,�%7/( C %yi. Inspector: � � /`� Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, *m 0 A , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade
at 3 F� ev P-eA rA S•
FEE
Abandoi�an individual sewage disposal s�stem
as described in the application for
Disposal System Construction Permit No.D dated :Z 2 'd`
Provided: Construction shall be completed within tli e-rcgr of the date of this permit. All local condition s m st be met.
Board of`
Form 1255 Rev. 5/96 AN. Sulkin Co. Boston, MA Date tom' / -Health
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