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No. l a F65-0 . 0 0
COMMONWEALTH Of /�►� TS
��'�v` YARMOUTH HALTH DP.
Board of Health, 1146 ROUTE 28 MA.
APPLICATION FOR DgsPOqRZ" ' CaXVUCTION PERMIT
Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location Salt Ln. Yarfneuthpert
Map/Parcel# 140/18
Owner's Name Tricia Titus
Address24 Old Salt Ln Yarmouth Ort
Lot#
Telephone# 3 6 2— 6 7 4 3
Installer's Name Wm E Robinson Sr Septic
Designer's Name Down Cape Engineering
Address PO Box 1089, Centerville
Address 939 Main St, Yarmouth
Telephone# 775-8776
Telephone# 362-4541
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
4
No. of persons
Lot Size
sq. ft.
Garbage gttt>tder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)!�t±ogpd 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 Install a new Title 5 leach system to
plans of Down Cape Engineering, #05-177.
1
The unde s'gn d a ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fure a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed `' Date
Inspections
11.k11 : $50.00
06 `�V f � L I FE
COMMONWEALTH OAF MASSA���J����� �,� y��� D�
Titus( �7
Board of Health, YARMOUTH AMILA.
CERTIFICATE Off' COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (X), Upgraded ( ), Abandoned ( )
by. Wm E Robinson Sr Septic Service
at 24 Old Salt Lane Yarmouthport
1
has been installed inf�ccordance with the provisions of 3 0 CMR 15.00 (Title 5) arld the approved design plans as -built plans relating to
application No. 0(0 Y44t, dated � � Approved Design Flo GS (gpd)
Installer 1 .1
Designer: Inspector: Date:
Y
The issuance of this permit shall not be construed as a guar tee at the system will function as designed.
No.X0.00
Titus �OIy1[MONWEA1314 Of MASSACHUSETTS
Board of Health, YARMOUTH MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( `:) Repair( X) Upgrade ( ) Abandon (. ) an individual sewage disposal system
at 24 Old Salt Lane, Yarmouthport as described in the application for
Disposal System Construction Permit No. O`/D¢ , dated 7..
Provided: Construction shall be completed within th 6, ars of the date ofthis e All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -3-37W Board of Health (-�/