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FEE
YARMOUTH HEALTH DEPT.
9-24-9/, �/jL_ Board of Health, 1148 p0�=� , MA.
9&14d /— APPLICATION FOP DISPOVtTffMftMUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location SQ Lp,vG l52.
Owner's Name Lao sEa-ulN/i��9
Map/Parcel# lr'au l j97/ 172
Addressdpe-� A.,Jp Pe- , PG-" t 5
Lot# s� / /� �� �.�
Telephone# 3655 -
85 -
Installer's
Installer's Name M, �, /t 11_7-,>7-rR
Designer's Name 10, C 1715$vC"
Address/(,3 Age ty jj,e y 12rj , /CSC . � �%�D�T OZE 7S
Address/6#57 F,4 LAWooN P -P , S U,Td 4 C' O',0-7ac V t
Telephone# 38�..,'- 9W7
Telephone# -77 J' " 07-57'4e
Z Z z
Type of Building Dw>�"ZL! N 6 Lot Size 4' —,q. ft.
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Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 00- gpd Calculated design flow Design flow provided gpd
Plan: Date `�- 3 OB Number of sheets / Revision Date
Title 5 17-E - 6 —'--2OA6,6 PLttt% FOA sd LoAuG Fe7LLoca D A , MI" 05"774
Description of Soils) _ -`��� -C-4A i
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator 1>A V&'-- "A -SO A-� Date of Evaluation q " ZO - 6 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 the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Ad, � . id Date Er -1 Z -G O
1 -Inspections -�
r
No. (/v NNOMMONWEALTH FMASSACHUSETTS
vCUE FEE Idn C/CJ
' Board of Health, MA.�
CERTIFIC OF COMPLIANCE
Description of Work: ❑ Individual Com onent(s) omplete System
P P
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The undersigned hereby certify that the Sewage Disposal System; Constructed �4, Repaired ( ), Upgraded ( ), Abandoned ( )
by; , C_ . 14
at 5"b Lo &JG EE-c,Low 7jfL. ,�i9 2NIdc�7��no 2T
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and tth-ee approved design plans/as-built plans relating to
application No. Z dated %lJ VApproved Design Flow !!-.t(gPd)
Installer
Designer: Inspector: Datery (/
The issuance of this permit shall not be construed as a guarantee dt the system will function as designed.
No.� /1\11re-lXZlec-
C®MMONWEALTH OF MASSACHUSETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
/: 611-7 7
Permission is hereby granted to; Construct (A Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 5�0 ZOaJ6F�-uoc-3 D9. , �-04k"O CJ7-H /00&0- --r- as described in the application for
Disposal System Construction Permit No. &V - 32 !7T, -dated 6 16
Provided: Construction shall be completec?within p � Sthe date of this pert . All local conditions must be m t.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �c� ` GC -pard of Health // X