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No. '04; i4 FEE
'L_.®MMO U'U' EA LT14 OF MASSA'L_ 14USETTS
YARMOUTH HEALTH DEPT. � � 5 4ee,�
Board of Health, _� nr -ov ROUTE 28 , MA. �
APPLICATION FOR DISPOSA?-MYfftftffWCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System3147 Individual Components
Location I
Z3 7"-y-; �-twcad
Owner's Name % j ,� M 6✓7j
Map/Parcel#
2-8 V
Address 12C3 r, ,P h,,o,7,/ Lyy-e
Lot# %
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Telephone# Id ir- 3 -i —6 -is)
Installer's Name
dv id
Designer's Name Sou ;W1<4
Address
i% U % �)< �� L "de -Address
q2-3 iZT rlW t h Qc +
Telephone#
S'6g %f 7-6 qo z9
Telephone# ,f'p?' 3Com,,Z9 j3Z
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
_ Lot Size z ZJ 2 S +^ sq. ft.
Garbage grinder ( )
No. of persons y Showers Cafeteria ( )
Design Flow (min. required) 3.3 U gpd Calculated design flow 3330 Design flow provided 3 �ff gpd
`/
Plan: Date (O'1q 24b 0 Number of sheets Revision Date
Title 1 2-4>
Description of Soil(s) 4ko— 44",
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS CA 5 L2 ) 5'W S 191 L e q -'g(,
Nej -9 -v5 ®x e=:,! � � s, 1. C w 921,�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no lace a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date�-
Inspections
No. V / (� �7��]Ej� FEE
Board of Health, Qkw,, %� 'Nm.
CERTIFICATE 6f COMPLIANCE A
Description of Work: ❑�Zidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (, Abandoned ( )
by: dpewl 04jP-ri s<l L►t.-
at 120 _ )C -.40-a \4Ar✓--
has been installed in ccord with the provisions o 10 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
applications/ No. dated `�� "0 . Approved Design Flow and
Installer (2'4,e,,, tC, (EVi1-e/0' 5 0-> L( -e. -
Designer: 2 Inspector: f' �% G Date:
The issuance of this permit shall not be construed
=guarantee guarantee th t the system will function as designed..
_ - No.
Board of Health,
DISPOSAL SYSHM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct ( ) Repair ( ) Upgrade (t�/Abandon ( ) an individual sewage disposal system
at l Z a )C, fW 'DO A A -J e SO -� � ���, as described in the application for
Disposal System Construction Permit No. 6 _,214/, dated -7 11
Provided: Construction shall be completed within:xh�r of the date of this prVr All local con4i'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date —7-1d -� V Board of Health `" Y'