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COMMONWEALTH OF MASSACHUSETTS
GbS 17
YARMOUTH
Board of Health, 1146 ROUTE 918 MA.
APPLICATION FOP, DISPO�%' CONSTRUCTION PERMIT
A plication for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) - ❑ Complete System [Individual Components
Location
L-, GowkIALE WA14
Owner's Name 5414_ t1XWS 7R
Map/Parcel#
134/9-7
'tv[
Address A296 �iEi�i l����7 CE EL
Lot#
Telephone#
Installer's Name CAPEwtDE 7zEga mss
Designer's Name N
Address 15
l�y4M S -r -qP(S-;5*
Address
Telephone#
5502- q-77.- 98-7
Telephone#
Type of Building Rr-_j npet_ I /Q -C.. Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
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 Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS _Tlis ew-c P Ve- -5,# tt1 qqfq7 Tce
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr es to t t lac a system in operation until a Certificate of Co plian a has been issued by the Board of Health.
Signed Date0-7/2-0/11
Inspections
No.
'L...®MM®NWEALT14®F MASSACHUSETTS ETTS �FEE -Oso
Board of Health, T A t o MA. � r` ai C
CERTIFICATE Of COMPLIANCE 614-
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Description of Work: �Ix�dividual Component(s) ❑Complete System ��7w�C� e�^�?��K �" �� Oal Te
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded .(_ ), Abandoned ( )
by: (2AP& iz)6 EXr ��2lSE5
at io&IJiUC.t A -L6 W,4
has been installed in actorx>,ce with the provisions of 310r CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ^ lG , dated! pproved Design Flow ` (gpd)
Installer �74p�C�JIj�C ��Ta�-lsZ rl-(QIA CAP /
Designer: WA Inspictor: Date: Hl � 117.
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 06s� (/(' eu f ve L FEE j 5�5 V6
Board of Health, 7 AoV MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct ( ) Repair (� Upgrade ( ) Abandon ( ) an individual sewage disposal system
at (m+
0 l� U& i WA\1 as described in the application for
/7/� ?
Disposal System Construction Permit No. , dated �
Provided: Construction shall be completed within three years of the date of this per it. W1 flocal con 'tions must be met.
55 Rev.
Firm 12 5/96 A.M. Sulkin Co. Boston MA Date oard of Healthv"4�
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