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No. 0 3 - /� FEE
o �..IP/001
Board of H aJA4 ROUTE 28
So. YARMOUTH,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade Abandon( ) - Complete System ❑ Individual Components
Location Owner's Name H j• e 6(j J -R,
Map/Parcel# 7 Z Address ply, sek 9158 , -�r;
Lot# %r Telephone# (W q if v2° 7-3,67 0 27 2z9
Installer's Name a Ce k S.S >14Designer's Name Donald W. Moncevicz, P.E.
Address 1 -7 7--' W^-., ,/��/� Address
Civil Engineer
40 Pond Street
Telephone# wp) 7g e4yy Telephone# West �Dennis, MA 02670
Type of %
Building ��/�i�i+�/�%�4/�- �zVal:'i���il��9 ® � Lot Size m,.'/5' 4P"s_=j--t.
Dwelling -No. of Bedrooms ,':�i�'s iiv6 '� Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min, required) 3 ('� gpd Calculated design flow Design flow provided 333. gpd
Plan: Date e (r r .23 , ;2-M-3 Number of sheets Revision Date
Title 1" ?'.lr' �ri; �3� i r'/�.a�' .'I,�eeo ✓",�✓Jrv"T
Description of Soil(s)
Soil Evaluator Form No. --��' Name of Soil Evaluator&5., /� Date of Evaluation ®G 7' �Z3" Ai
m
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 place the sys min operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed 'f Date
r
Inspections
0
No. -0,3 ._ FEE
COMMONWEALTH Of MASSACHUSETTS�.
O i Board of Health, d4 v r MA.
- r
CERTIFICATE -®f COMPLIANCE W 2 ��. � F
Description of Work: Ll Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( Repaired ( ), Upgraded, Abandoned O GWS (1
at R,,?— .I_' lx:!-ru imb ,.11..
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. t'.) 7; -4 =' dated Approved Design Flow (gpd)
Installer 120 -117 -Al KL/L4" fi " 'f f t
Designer: ,;i";7L%c ft1 fC `7/�1� Inspector: Date: ar n
The issuance of this permit shall not be construed as a guarantee that the system will fitn4tion as designed. I
FEE
Board of Health, 4k*kO °"' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct Repair( ) Upgrade(X Abandon( ) an individual sewage disposal system
at AR /ems 7 WC,V131 ° as described in the application for
Disposal System Construction Permit No. - �,�J, dated
ow.>
Provided: Construction shall be completed within tlrs of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 't�✓ Board of Health