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No. (/� z FEE
COMMONWEALT14®f MASSACHUSETTS
Board of Health,
YARMOUTH HEALTH D�,PT.
APPLICATION FOP, DISPOTRLYN xea
Application for a Permit to Construct( ) Repair( ) Upgrade( Aban mts
Location 36 5 liG
Map/Parcel#
Lot#
Installer's Name
Address
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
STll�Apt?
C'u�� • � �'orar�t4laCC�/t/ �'�ivdiC�
co!0
r/et cc, ;1194 /h 61/�d�6 SJ
fir• g s.�l�Sei/� ��p
YO�L yStcrl� h�V/ie� &Y sq. ft.
J' /h5 rl/ /S�7 r.*k /� trc��r� grinder ( )
QQe= K �YT tL
E 5
-k-Je- afeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow :5 -3V Design flow provided gpd
Plan: Date �,�/Z� 'epi Number of sheets / Revision Date
Title6�
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above describ3,ed'51hidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no to place the in operation until a Certificate of Com fianceh been issued by the Board of Health.
Signed /Date 0
No. e,2 —52, j11 17 �/rPC L/0! FEE
Board of Health, AIA.
CERTIFICATE OF COMPLIANCE
Description of Work: .Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded(.Abandoned ( )
at ���n i s 4fi_ _i�
?�
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. % ` 2- , dated .2 Approved Design Flow �3 (gpd)
Installer
Designer: .�(%' (--.� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that 4e system will function as designed.
-- —__
No.��G/�//4' [�/�C�f/G✓�/r'te FEE�(/c-'
C®MMONWEALT14®F MASSAC14USE` TS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (/Abandon ( ) an individual sewage disposal system
at -'3 �"A i` ye r as described in the application for
Disposal System Construction Permit No. &02-U—, dated . —111'44 2..
Provided: Construction shall be completed within dTree'r5rs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Bdston, MA Date / r VBoard of health