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YARMOUTH HEALTH DEPT.
1149 ROUTE 28
' 9a. YARMOUTH, MA 02864
COMMONWEALTH OF MASSAC14USETTS
i Tc FEE 100
p 1) Ct-,Zt0/
Board of Health, MA.
Oft.LICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( - OComplete System ❑ Individual Components
Lo , tion 9- J' L Z)CI-/ /2A/� or /7 It/^ y
Owner's Name
Map/Parcel# /32. / SS—
Address )D %cQ X A%11,04, CS Tek vr1%,
17
Lot#
Telephone#Q� - �,f- ?-,?Z,c
Installer's Name.
Designer's Name -S SE' R-'
Address
Address 23 �,Q e %%CJ N k,0
Telephone# 7 7
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. re uired
Plan: Date 1 Z�I/
Title
F2
No. of persons
Lot Size sq. ft. _
Garbage grinder (/W
Showers( ), Cafeteria ( )
V YQ gpd Calculated design flow
Number of sheets Revision Date _
,3
MA WATS 1-800-242-3878 N.E. WATS 1-800-343-3878
Description of Soil(s) _ FAX F.R. (508) 678-2842
Soil Evaluator Form No. Date of Evaluation
9- gpd
OB/NSON
KSUPPLY CO., INC. G�
DESCRIPTION OF REPS Cv Jft I `t te-t Air Condihoning & Hearkv
SETH ST. ROMAINE PAGER: (978) 488-6146
SALES FAX AND HOME: (508) 760-3730
FALL RIVER HYANNIS CRANSTON .
The undersi ed agrees WOBURN PLAINVILLE accordance with the provisions of TITLE 5 and
further i t t to _ as been issued by the Board of Health.
Signed / Dater -
Inspections
_.
No C16 --OIL FEE d _
C-OMMONWEAIT14 Of MASSAC14USETTS
i Boazd of Health, Gil W%Z-� ' , MA. i�3 r:lTC_
P
CERTIFICATE Of COMPLIANCE
j Description of W�k: LI Individual Components)plete System
1
The undersigned hereby cce/rtify that the Sewage Dispp 1 System; Constructed repaired ( ), Upgraded ( ), Abandoned ( )
at 2 S bac. H )2 IQ 1NN c)c
has been installed in accordance with the
application No.16- J�G , dated ?
Installer i�d --N C o ff t -0 cnn s T
Designer: SLAje 5Yr,1&7:. • -�Y
The issuance of -thispermit shall not ,be cc
ovisions of 310 6iR 15.00 (Title 5) and the approved design plans/as-built plans relating, to
. Approved Design Flow .(gpd)
Date:
31 l
Inspector: DQ
trued as a guarantee that the system will function as designed.. 0M *,d a• 1 ��P
No. -/ FEE
COMMONWEAITjj OF MASSAC14US ETTS
Bard df Health, MA. g �+
'1 Y
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( -<_Repair( .)' Upgrade( ) Abandon( ) an -individual sewage disposal system
at P- S 400- N R )+IVNo c as described in the application for
Disposal System Construction,Permit No., dated
(10 anwn S
Provided: Construction shall be completed within tkrer-rem's of the date of this. per t. All local nditions must e met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 3 Board of Health