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No. 71
FEE r
YARMOUTH REALTH DEPT.
/,z/Azr/--,6-z;r-COMM6)XWDAII*Of MASSACHUSETTS
SO. YARMOUTH, MA 02644 44ml
1&-Gi✓�' Board of Health, , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(/I"'Abandon() - Complete System ❑ Individual Components
Location 9
Owner's Name
Map/Parcel#
S1f r Address
Lot#
o Telephone#
Installer's Name
c
Designer's Name
Address //,-;'
Address Flo
l
Telephone#
Telephone#
609 3A, ;,4
Type of Building :D56), E / q 4;;-� Lot Size //&Z3 sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 336 gpd Calculated design flow s33 0 Design flow provided 33-Zr A-1 gpd
Plan: Date �.ZS�D .TJ Number of sheets DN F— Revision Date 5�I&/O 7%1)
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 3 .ZI DiiJ
DESCRIPTION OF REPAIRS OR ALTERATIONS :k F-PLAc E CE -,;s 00,6 C)/-,;
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a pot t pl a th s tem in operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed ' Date
p r-��� aL
Inspections
No. COMMO V'V' ir.ALT14 Of MAS 14IlJSETTS FEE
Board of Health, MA.
ERTIFIC E Of COMPLIANCE
Description of Work: El Individual Component(s) Complete System
The un igne hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded /Abandoned ( )
by:
at
P. -
has
has been installed in accordance with the provisions o j310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 02--.2-3'5dated Approved Design Flow
Installer
Designer: �/1 / Inspector: Date: /
The issuance of this permit shall not be construed° as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,MA.
T ,
DISPOSAL SYSTEM CONS�RIUCTIONPERMIT
li
FEE -- G
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Permission is herebygranted to; Construct( ) Repair( ) Upgrade( k) Abandon( ) an individual sewage disposal system'
at / i. G 1,-6 /% as described in the application for
ry2PrDisposal System Construction Permit No. 02 dated 6 - 7,02—
Provided:
ovided: Construction shall be completed within4h,(&% of the date of this permit. All
'focal conditions must be met. t
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston�,MA / T Date _ / O2 -Board of Health
?05A';41 27? .%, iSP 7 7' . iii yrs _ai�/7