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YARMOUTH HEALTH DF-Prr.
1146 ROUTE 28
S®. YARMOU-nl, MA 02664
C®MMONWFAIT14 OF MASSAC14USETTS
Board of Health, fQrI'V®w,*-/ , ..
FEE
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(�bandonO - l'7 Complete System ❑ Individual Components
Location 5 0M Q'
Owner's Name
Map/Parcel# 1%3 /Q41
Address
Lot# Gf
Telephone#
Installer's Name gOtyp14P /01-/ Go�a:s,
Designer's Name
Address `7 S
Address ff3r
Telephone# 7 I
Telephone#
Type of Building �`� /Gt/�'d�oC_-
Dwelling - No. of Bedrooms.
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date G
Title C_/
Description of Soil (s)
Soil Evaluator Form No.
Lot Size
No. of persons
sq. ft.
Garbage grinder (11(-�
Showers ( ), Cafeteria ( )
L,40� gpd Calculated design flow 3 3 e Design flow provided gpd
�g Number of sheets Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
/r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of to e system in o eradauaintil a Certificate of Compliance has been issued by the Board of Health.
Wried Date
Inspections
No. ,za FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, >ell- �L/7�"�I MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) W,&mplete System
The unde✓rJsigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. �P �iO 77-, dateddj 6 �` �� Approved Design Flow 3� (gpd)
Installer F4 L 077/ C G. -
Designer: ljb��dn / t�A/�� Inspector: ate:
The issuance of this permit shall not be construed as a guarantee that the s em will function as designed.
No. ( f 0 �7'a L ,d 7-7`/ C. C9 7�/ P FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Me.Js'%, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Cons ct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
S3 ��� r
at � as described in the application for
Disposal System Construction Permit No. `".� / , dated
Provided: Construction shall be completed within three years of the date of this per it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -& /-4 Board of Health
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