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No. Y ; a „ FEE '
Ile 0vd / Board of Health, YARMOUTH HEALTH QEIT.
APPLICATION FOR DISP® v , W4 UCTION PERMIT
Application for a Permit to Construct() Repair() Upgrade 4 Abandon() - ✓ Complete System ❑ Individual Components
Location-���/%7���?. %/d'cP,
Owner's
Map/Parcel# 4:<1?-
Address
Lot#
Telephone#
Installer's Name z4`994e4 r
Designer's Nam
Address ;:;� �<Ti�,e-,- - ,oYj/,
Address
Telephone#j j �i°� 3,� 6' 7 ,-7 j?
Telephone#
Type of Building �/�
Dwelling - No. of Bedrooms
Other - Type of Building
ill -
EM
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated desi n flow Z� Design flow provided gpd
Plan: Date Number of sheets Revision Date /— 3,1-6, 6,
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 agree�,t
t t '?ace the syst.,in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Z /.��sJ Date
Inspections �l � o - 0
COMMONWEALTH OF MASSACHUSETTS.7,-
Board of Health, 641 W MA.
CERTIF;Zmplete
E Of COMPLIANCE
Description of Work: ❑ Individual Component(s) System
The undersigned hereby certify that the Sewage Disposal System; Constructed (4,kepaired ( ), Upgraded ( ), Abandoned ( )
by: � l '1'yJ G - — �-
at "P
has been installed inAccor with the p o stons ofY0 CMR 15.00 (Title 5) and th approved design plans/as-built plans relating to
application No. "� ated / -a Approved Design Flower (gpd)
Installer
Designer: `% ,1 i��Inspector: Date:
P -- _ that thtem will function as designed.
The issuance of this ermit shall not be construed as_a guar to . _ .
No. �✓ /DJu !� FEE
Board of Health, `'f G� Olt
DISPOSAL ST CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at /Z ..& as described in the application for
Disposal System Construc oxermit No. L, dated.
Provided: Construction shall be completed within th4:e�of the date of th'PI
unit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. BoO n, MA Date Board of Health
41)d / �,�- . / ,// r�