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No YARMOUTH HEALTH DEPT.
Selz-� � 30. YARMOUTH, MA OM4
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct/R pair() Upgrade() Abandon() - Z Complete System ❑ Individual Components
Location Z 3 6 Ce�Wle:o�
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Owner's Name*6,.,,4/,t0
Map/Parcel# 1 �w -� Y j
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Address 2.. 3 (o/ (f&71,--iV-c !� T
Lot# Z ��
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Telephone#�2- ����
Installer's Name -3
Designer's Name coo-?. -wa AKG L [e
Address cS�,
AddressC%1 q J 1 D
Telephone# S f v
A OZO - s S
Telephone#�7 (� L s c�
C. 6" ems& ¢ e__ L ��l�?CSL Lot Size s ft.
Type of Building q.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 O gpd Calculated design flow 3 3 O Design flow provided3 l gpd
Plan: Date l -lO Number of sheets J Revision Date
Title �! <G� o$:574-d�''rf'' L&K
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator 5. /46L 11* SDate of Evaluation ?— Z �7
DESCRIPTIONCOF REPAI RAL�!TERATIONS
l W i Z� �.h •"A S-0- G
C,. oe,—," lisp-4e� torr __ >
Sth ct rc pt
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the pro/il",of TITLE 5 and
further agr to not tUplac the syste o ration until a Certificate of Compliance has been issued by the Bo d of Health.
a> Signed Date"
. Inspections
4/� S
No. FEE
COMMONWEALTH OF MASSAC14US ETTS
Board of Health, 112 ey/ / , MA.
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C ERTIFICA ®F COMPLIANCE
Description of Work: ❑ Individual Component(s) Ue5-1-�plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired ( ), Up raded ( ), Abandoned ( )
by: /� /d'Z !A/� - C fr l/c %/'� 6 GJ' E ✓I�/C /
has been installed in accordal ce with the rovisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No.�% 'c�� dated 'D I Approved Design Flow (gpd)
Installer DiC C t' /c, C C, / A 5
Designer: /.f/Z Inspector: � Date:
The issuance of this permit shall not be conv6ued as a guarantee that the system will function as designed.
No. -��� G- FEE fI/
COMMONWEALTH OF MASSAC14USETTS
Board of Health, Li//� /�'% �i� �J !7` , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(/ Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 0�/�" ///6�2/ as described in the application for
Disposal System Construction Permit No. `` .S dated
Provided: Construction shall be completed withirs of the date of this permit. All local conditionsm t be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health
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