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COMMONWEALTH OF MASSACHUSETTS
YARMOUTH HEALTH DEPT.
Board of Health, 14 ACUTE 74 , MA.
APPLICATION FOR DISPOgRfY "M'M?MUCTION PERMIT
Application for a Permit to Construct( ) Repair (N Upgrade( ) Abandon( ) - ❑ Complete System Xlndividual Components
Location
RA
t f
Owner's Name 1,QY Pc5D-Fk
Map/Parcel#
g-9 I
Address'' , �AYA oubAl SY
Lot#
Telephone#
Installer's Name Cf� ib
�Zfl�P�I�
Designer's Name 01A
Address153
5
S tj pt9:F
Address
Telephone#
Q _ 4-2 '1 a $ 2 7
Telephone#
Type of Building
Dwelling - No. of
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
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 nlac a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 3o -aa I -7
Inspections
Y No. W 1 C ` 1 .1 r^ FEECOMMONWEAITHQF MASSACHUSETTS
Board of Health, 7` Apx-eU ,.MA.
CERTIFICATE Of COMPLIANCE
Description of Work:. KKndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (�; Upgraded ( ), Abandoned O
by: QA -Dr- Cq_.) c b
at 7'�l_A AY6u o 1,J:j +Q' VE
has been installed in accordance with' the wovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application Nno. dated - ` % AXroved Aproved Design Flow (gpd)
Installer V ''iJ(
Designer: Inspector, Date: %4 777
The issuance of this permit shall not be construed as a guar ' (,e that the system will function as designed.
No. /'^t �-�( T �� W C I�.l T�' Y FEEL
-f COMMONWEAlLT1 Of MASSAC14USETTS
Board of Health, iA Moo b , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) RepairUpgrade.( ) Abandon( ) an individual sewage disposal system
at ( R� y�l�nxJ?� Ay6 J � as described in the application for
y
Disposal System Construction Permit No. I ` /"/, dated
Provided. Construction shall be completed within three yeas of the date of this permit. All local co i* ns must be met.
Form 1255Rev. 5/96 A.M. Sulkin Co. Boston, MA Date //Board Of Health
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