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COMMONWEALTH Of MASSAC14US E` TS X s
YARMOUTH H6AL1; wr
Board of Health, 1146 ROUTE 28 ' MA.
APPLICATION FOR DISPO�UTM'MOtUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
LA -t R 4 ry t.-1
Location 0 Q v c, v- t5LA 79:NyT
Owner's Name C-0 4P
Map/Parcel# d G a
Address 3 o Q ck-- ISLA-KD W
Lot#
Telephone# 1�- 0 9 - 775 --5 %
Installer's Name �����
Designer's Name
Address 153 �'�- 5���
Address
Telephone# SOF,,., 47Z -9 277 1Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
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
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS (.J JV 6 C qA1 )C-,Cg-( aL)r LVL 0&, 7-0
3C -I? -CLC- -Merv-
gpd
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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed/ Date
Inspections
No.
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, _ Yj HA2 eJTb4 MA.
FEE
CERTIFICATE OF COMPLIANCE Z,,
Description of Work: , Xndividual Component(s) ❑ Complete System Cj, �* Al
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (' xt Upgraded ( ), Abandoned ( )
at 3 On RLJC-t- 7:,5,L 1 jb Tz�h
has been installed in ac orce with the rovisi s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated 7. Approved Design Flow - (gpd)
Installer CAPeWtb6 SS
V2TheDesigner: N/A Inspector:
(OW Date: 'F--// V2—
The
issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. O C - ' bZ� oAJ ���" FEE
. Board of Health, YARoq,,,7 7 4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (X Upgrade( ) Abandon( ) an individual sewage disposal system
at 3w TBU C -y-. P,`) � p as described in the application for
Disposal System Construction Permit No. 7, dated
,&y�WGVg
Provided: Construction shall be completed within -&&
of the date of thisp;{nit. All local co itions must be met.
For 1255 Rev. 5/96 A.M. Ikin Co. Boston, MA Date
t ^ / 7/Board of Health C
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