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COMMONWEALTH OF MASSAC14USETTS
YARMOUTH HEALTH DEPT.
Board of Health, 1146 ROUTEE 28 , MA.
APPLICATION FOR DISPO AMY t R-MAVUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location /o/ 1K S' 1M An (- di -7—
Owner's Name
Map/Parcel# �/ (p
Address MA A19,
Lot# ft� 7
Telephone#
Installer's Name ,q yy�S
�0+
Designer's Name
Address iT (�o-,<
q,:�:) � �r.�� I
Address
Telephone# ` 009- F6D--
1�3z-/(b
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
h
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd-
Revision
pdRevision Date
Date of Evaluation
The and signed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrft to not to placesyste in operation until a Certificate of ompl'ance has been issued by the Board of Health.
Signed (1 Date GLS 1
e Inspections
No. -1 S� FEE
COMMONWWT14 Of MASSACHUSETTS'
Board of Health, 7G % MA.
CERTI 'ICAC OF COMPLIANCE
Description of Work: A Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepairedV), Upgraded ( ), Abandoned ( )
by: 4 t✓"o- S Y 0" cl
at /01 A 11rUMAn 1,<t Vt Iq n,YYtW-k !0G 14
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. 6 � - PT e , dated --f - /? +U /. Approved Design Flow (gpd)
Installer o//7,04et t Lvc/J
r
Designer: '` Inspector: A',f l L° t`�FFDate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. d/..
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1 97V , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at /0 1 14-elmsmA�i 'b(1Je- 'Y4K (JOLT as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within the the nate of this. permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date'( 1 —C-" / Board of Health