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COMMONWEALTH OF MASSACHUSETTS
YARMOUTH HEALTH DEP'.
Board of Hea4i,A68 ROUTE M , MA.
APPLICATION FOR DISWA"MMWOMTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() ❑ Complete System ❑ Individual Components
4
Location M (Al /
C
Owner's Name G
Map/Parcel#
Address ,j Q 45j) fir'
Lot#
Telephone#
Installer's Name
6�vS
Designer's Name
Address
f
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
D,' =�gn Flow (min. required)
Plar: Date
n
Description of Soils) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date _
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1�e�e�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to ac the tem in operation until a Certificate of Com lia a has been issued by the Board of Health.
Signed f Date ///�
Inspections 4."1 1.
No. l�( FEE x ! �,
COMMONWEALTH OF MASSAC14US ETTS
Board of Health, it s"/.�,plg 1�' MA. 7,WL{
d
CERTIFICATE Of COMPLIANCE
Description of Work: 11J' -Iidual Component(s) ❑ Complete System
The undersi r�,ed hereby certify that the ewage Disposal System; Constructed ( ), Repaired Upgraded( ),Abandoned( )
by: 9 . 11�
at 7&1 �,1 ro !�
has been installed in accordance with the provisions 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 0-�, %-3, dated 4 _Q Approved Design Flow -""` (gpd)
Installer /0 r-�ZaI—;"-`
Designer: Inspector: /, r /' l G J j J Date:✓-� t'
The issuance of this permit shall not be construed as a guarantee thdt the system will function as designed.
No. / `` Y 't%�CG FEE �L`r
Board of Health,/Gr 0 l°%�C.� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (!,<Upgrade ( ) Abandon( ) an individual sewage disposal system
at _S 1p �j' !1J l�L='. ' f-1- drA---e as described in the application for
Disposal System Construction Permit No. 0-:> — , dated %'/-
Provided: Construction shall be completed within_IU�rs 6f the date of this permit. All/local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date fl—l' l J3 Board of Health