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No. i FEE
C®MMONWFALT14 OF MASSAC14US ETTS elegy
YARMOUTH HEALTH DEPT.
/ OI/w/ Board of Health, TTS ens TE 28MA. > Av/ e,
APPLICATION FOP, DISPO9RMMN-MRMUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade �,<Abandon( ) - Q Complete System W11ndividual Components
Location 3.5–.5
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Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
esigner's Name
Addressr
10000 al
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d%�t
Address
Telephone#.�
Telephone#t7 —,'cr'–�
Type of Building Lot Size : sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 0 gpd Calculated design flow Design flow provided + gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator 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 a es to not to lace in operatio until a Certificate of Co pliance has been issued by the Board of Health.
Signed Date
Inspections
No.FEE 'i V
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
Description of Work: WIndividual Component(s). ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ) Repaired ( ),Upgraded Abandoned ( )
at -=
has been installed inaccordancewith the provisions of O CMR 15.00 (Title 5) and rff pr veal design .plans/as-built plans relating to
application No. dated 7% :Approved Design Flow gpd)
Installer 1 P c " 2 y1 ,
Designer. .� e,' "i dg Inspector: < Date: 6
�r
The issuance of this permit shall riot be construed as a guarantee that the system will function as dzsigned.
No. elf
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per'7-/ -- --- - - FEE --IV V
COMMONWEALTH OF MASSAC14US ETTS
Board of Health, I MA.
DISPOSAL S YST CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( )> Upgrade( )' Abandon( ) an individual sewage disposal system
at .T l . . ` (. �� as described in the application for
Disposal System Construction Permit No. (� -�yl dated
Provided: Construction shall be completed within thTre:4ze�s of the date of this permit. All local conditi ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston; MA Date _i!� hoard of Health/ lY J