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No. o 14 DC" 1-7A33-7 FEE 4615,00
A OMMONWEALTH OF MASSACHUSETTS
YARMOUTH HEALTH DEPT.
/ Board of eal H , MA.
�1
PATI®N FOR DISPT%-VRWMtTtMftRUCTION RMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - C3 Complete System dividual Components
Location
(B1 WJ
Owner's Name 'T'/ M 6TOLI 6✓�5����r
Map/Parcel#
g (
Address & AQ(010 c51- (, J07- AW1,(0`/714
Lot#
Telephone#
Installer's Name (W6wa i 5
Designer's Name
Address 15-3
Address
Telephone#
_ 7 -t 19 '7'1
Telephone#
Type of Building Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) _ gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS i). & LSev,� C/--,,, 0--, e 5 M I o 6S d I A It'j"
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. C�ciH��-� /-y�37 FEE Od
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, AkPJ O LZa r , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded-�, Abandoned ( )
by: C!APe&2tbgQpt2�5
at to 1-A w .5-r& 5T W e;r YAak6ot 4
has been installe in accordan with the ro��is ns of 310 CMR 15.00 ('Title 5) an the a proved design pians/as-built plans relating to
application No. %' dated I—/ 7. Approved Design Flow (gpd)
Installer
Designer: W— Insp
The issuance of this permit shall not be construed as a
No. 6oAA Dc -i%-433-7 E-V,)1�C> �5,
COMMONWEALTH Of MASSAC14USETTS
Board of Health, '/4Rjup 07-d , MA.
FEE 456-- Qb
DISPOSAL SYSTEM CONSTRUCTION PERMIT OU
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon(
at
Disposal System Construction Permit No./ 7 l , dated
Provided: Construction shall be completed within trsof the date
Form 1255 Rev. 5/9/6 A.M. Sulkin Co. Chadestown, MA Date ?Board of Health
l9r.1� A %% a?(' -(�;r 11r - AW //
an individual sewage disposal system
_ as described=iii the application for