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COMMONWE,
YARMOUTH HEAL'f
Board of Health, 1146 ROUTE 2$ MA.
APPLICATION FOP, DISPOWMM'MNS TRUCTION
FEE
E�A1V
JUN -15 2017
TH DEPT 9
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location
a V,
Owner's Name T"Aj E 640-f5Tt,0 5140 O'
Map/Parcel#T
Address Eptos k#j
Lot#
Telephone#
Installer's Name�i�i
�� sS
Designer's Name Q
Address js
_404t,ST. M,4Sd,)CX,Address
ete
Telephone#
(g - 4-17 - 9
Telephone#
Type of Building ReS ib7-'/A-L— Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd-
Revision
pd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS 64BdAA5, iLwAd J C. X)6 FR✓fiA, CSV T�A�
TD HAW CES? O c,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre s to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed A Date 14,-15-1-7
Inspections
No. 13 N - ? -q -7 0 FEE ,OU
COMMONWILALT14 OF MASSACHUSETTS
Board of Health, I I�-RN o rrI `'1 , MA.
As
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) L1 Complete System4
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (A), Upgraded ( ), Ab ndoned ( )
by:LwU EWKYRUSM'
at 10 CVERGC 1--t Porgy W SZ YAhjMQV-W
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. - /' , dated /. Approved Design Flow (gpd)
Installer6(01b6,c14 Kd o l owo pp 1J
Designer: NLA Inspector: /' Date: -)/Cg
The issuance of this
permit shall not be construed as a guarantee that the system
�-will
yf�unncttion as designed.
`i
No. �0%l I ! `" ! 0 � CAV E11 � C' !`� t �-I� Ic�t S FEE 36 - V 0
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
DISP®S L,, .SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Co"nnstruct(_ ) 'R.e 'pair (X) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at i - C`C-07'4/ as described in the application for
Disposal System Construction Permit No/ /7 W - dated -;;� -17
Provided: Construction shall be completed within three years of the date of this perms l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date b oard of Health
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