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Board ofHealthi ARMOUTH HEALTH DEP146 ROUTE 28 -1APPLICATION FOP, DISP@9ATFRI��_(MRUCTION PERMIT
Application for a Permit to Construct( ) Repair(-rlUpgrade() Abandon() - ❑ Complete System LlIndividual Components
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Location
V
Owner's Name fc,3 E i lke
Map/Parcel#
3 G7 p 4P
Address A5 h (AX C ( LC,-,
Lot#
-f'7 — A/&X l
Telephone# er - (OJ
Installer's Name
Designer's Name A4 j.So K
Address
350 Main Street
Address
Telephone#
W. Yarmouth, MA 02673
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow ::�W Design flow provided gpd
Plan: Date Number of sheets Revision Date
Tifle S / f tSiG CJ+4 �i /{
-Description of Soil(s) At t P ly
Sail Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS f e- P IN A N
A
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed L� d l ((/rl_.! •- Date %^oZ (c . �
Inspections
No. X ` J9(�
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Grit ut . , MA.
CERTIFICATE Of COMPLIANCE
FEE S-0—
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L ,te � :5 1-77
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (-), Upgraded ( ), Abandoned ( )
by: C /`t /U Cy
at 3 s 4fc A . /2 04 _ has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. 6V - , dated %"'5 /` Approved Design Flow (gpd)
Installer CV p
Designer: Inspector: Date:
�, as - s a arangu _�y tee that the system will function as designed.
The,yssu�nce`of_ tls.p
ernut shall not be construed -
No. �'2s' FEE S-0
COMMONWEALTH Of MASSAC14USETTS ije fe iv 3,4w,
Board of Health, �G�G� , MA.
DISPOSAL SYSTEM STEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( &()'/Upgrade( ) Abandon( ) an individual sewage disposal system
at ? , cc 0 2p. . as described in the application for
Disposal System Construction Permit No. dated _7-!(
6 eco s.
Provided: Construction shall be completed within tearsof the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �i _Board of Health / (_/f%�/ E!C�