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COMMONWEALTH OF MASSACHUSETTS dig Oil
Board of Health, YARMOUTH HEALTH D5K.
APPLICATION FOP, DISPO Y , W�UCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System. ❑ Individual Components
Location 104Owner's
Name
Map/Parcel#(' „.
Address
Lot#
Telephone#
Installer's Name '°
Designer's Name
Address
Address /
Telephone#
Telephone# _Z3 lia
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms �1 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) !� gpd Calculated design flow Jh� Design flow provided) gpd
Plan: Date b L Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a tto plac a sys m in opeYation until a Certificate of Comp 'anc has been issued by the Board of Health.
Signed K)o t i'�iirL Date
Inspections l;f YldeL�T'�G2 �GCL�SS/�1/
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No. &1/—oV FEE
COMMONWEALTH OF MASS CHUSETTS a
Board of Health, MA. f
CERTIFICATV OF COMPLIANCE
Description of Work: ❑ Individual Component(s) L7'Complete System
The u ersigned he eby certi at the Sewa e Disposal System; Constructed ( ), Repaired ( ), Upgraded ( y AAbandoned ( )
by: w
at ii
has been installed in accord with the provisions o/� 310 CMR 15.00 (Title 5) and the a}proved design plans/as-built plans relating to
application No:. Lam! `�CJ vim, da -:,2s�0! Approved Design Flow (gpd)
Installer _ _ A
Designer;1. 1- tLL -Q0-4AA Inspector:
The issuance of this permit shall not be construed as a guarantee
Date: c�
system will function asdesigned. "
No. d 5->v et �7x( /Ir/1016
COMMONWEALTH, OF MASSA HUSETTS
Board of Health, , MA.
DISPOSAL SYSRM CONSTRUCTION PERMIT
Permission is here granted to;
at � 04 `
FEE
Upgrade( Abandon( ) an individual sewage disposal system
as described in the application for
1
Disposal System Construction Permit No. ��-t%, dated
Provided: Construction shall be completed within is of the date of this per"it it. All local conditions miust be met.
Form 1255 Rev. 5/96 A.M. Sulkiri Co. Boston, MA Date �Z ���Board of Health
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