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No. (✓/ fit- /`�
� FEE o
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YARMICUTH HEALTH
APPLICATION FOR DISPOIAWY��MAWCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(k Abandon( ) - r.omplete System ❑ Individual Components
Location/,Q //��
Owner's Name `7" _� (:g/ZZ
Map/Parcel#
Address C
Lot#Telephone#
- - 3
Installer's Name �d�
Designer's Name
Address 926 P0,14-127AC
Address 2
Telephone#Telephone#
Type of Building _, Ze_L_-
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
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 lace the em ' peration until a Certificate of Compliance bin issued by the Board of Health.
Signed / Date
Inspections
No. el % 'ISI FEE
COMMONWEALTH OF -MASSACHUSETTS
Board of Health, G�� %!�1 MA. V ` V
C ERTIFIC COMPLIANCE p
Description of Work: ❑ Individual Component(s) L VComplete System
The undersigned hereby certi that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accor ce with the provisions of 310 CMR 15.00 (Title 5) and the a ved design plans/as-built plans relating to
application No. ��� dated Approved esign Flow�Yd),�/ �
Installer
Designer: 1 lee IK`F%l 2' Inspector: Ih % Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
Board of Health, '�/G%!f?7� MA.
/
DISPOSAL SYSTEM CONSTRUCTION PERMIT
�.l
FEE
Permission is- hereby granted to; Construct( ) Repair (f/) Upgrade( ) Abandon( ) an individual sewage disposal system
at �jas described in the application for
Disposal System Construction Permit No. �� dated ,7` /,;—c17
Provided: Construction shall be completed within & rs of the date of this peFmit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ..2 7 Board of Health