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No . 1146 ROUTE 28
SO. YARMOUTH, MA 02664
fW-,V)MMONWEALTH Of MASSACHUSETTS
6pv h)�j 53 • -Board of Health, AL4.
APPLICATION FOR DISPOSAL SYSTEM
FEE a4 co
CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ®'Complete System LJ Individual Components
Location Ift
Owner's Name � b j/yj Jo
Map/Parcel#
Address 3v C
Lot#
Telephone#
Installer's Name
Designer's Name
Address q C
Address OX 64
Telephone# ? 7 51--
Telephone# F3 E 2
Type of Building Lot Size _9;� 3a a sq. ft.
Dwelling - No. of Bedrooms F-6 vA Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 110 gpd Calculated design flow
Plan: Date 6 // 6 / 2R Number of sheets
Title
Description of Soil (s) _
Soil Evaluator Form No
Design flow provided f n gpd
Revision Date
Name of Soil Evaluator -T V 444-y- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Aj st--3 S Qa6c,S ✓ST -� '� �i A }p�u7 T1s E d ctQ
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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 Date -C /a/ q t?
w
Inspections
i
Tf
9�6
No. COMMONWEALTH V'V' EALTH ®f MASSACHUSETTS FEE /(70.
Board of Health, '!'liXL4=� MA. --ao t
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) OIComplete System ¢�
The undersigned hembycertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( 01,
at 4A
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 0 _->47d , dated (" �7V �t'. Approved Design Flow (gpd)
Installer 601 f * i S3 [ / lj--- a
Designer: L E7 Inspector: Date:
/
The issuance of this permit shall not be construed as a guarantee that4e e system will function as designed.
0 -
No. V -%/�� j�l L /t - FEES%�t� e.
COMMONW 1T11 Of MASSACHUSETTS
Board of Health, �'q,� b pt 4_, MA. G
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Permission is hereby granted to; Construct( epairU'paV(rr Abacloi�) ajncivdna`lsvagespttosal system
at �� � �_ ..� ; .., ti detscribed in the app6ation for
Disposal System ConstiXction Permit 0. 1� E'�> , dated
Provided: Construction shall be completedvfithm gee �ears'of the a of this permit. All 4o c%idi�ons must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA DateC7 d" nBoard of Health fig+
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