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No. D r/!_ ✓ �C� LC�/✓�////��L�` FEE �v /
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//t��YARMOUTH HEALTH DEPS
oard of Heal t ,�
APPLICATION FOP DIS R4 CO RUCTION PERMIT
Application for a Permit to Construct( ) Repair (4/U"pgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location ( C e VU
Owner's Name
Map/Parcel#
Address
L'ot#
Telephone#
Installer's Name47-7,
Designer's Name"'/'F-,,,Al CA ®jLL y
Address /7 W( cyG
Address LX1 'a S� .
Telephone# - of j""�
Telephone# %
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms T� Garbage grinder (Po
Other - Type of Building ` No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) L 4 gpd Calculated design flow 3 U Design flow provided 3 t gpd
Plan: Date r'/ Number of sheets Revision Date O tiL
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Ci�'/i Y %�if c- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �� .S� I� UaC � !' l �w I/� �� to S Uh S
a:
4
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
`"£tether agrees to not to pla a the system in operation until a Certificate of Compliance has been issued by the Board of Health.
ZY
Signed (/� r��i�-- Date
-Inspections
N
I
No. FEE G� C
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �/%' MA.
�. CERTIFICATE OF COMPLIANCE
P PComplete
Description of Work: "Individual Com onent(s) ❑ S Ystem
The undersigned hereby certify hat the Sewage Disposal System; Constructed ( ), Repaired /LTpgraded ( ),Abandoned(
((/)
by:�
has been installed in accordance with the �provisions
_of3„10 CVIR 15.00 (Title 5)and thea proved design plans/as-built plans relating to
application No. �7 , dated proved Ptsign Flow (gpd)
Installer /
Designer: _ (/sf Z46e G& °' Inspector: BOAAA Date: r� d z'
The issuance of this peraut shall not be construed as a,
guarantee that,the system will function as designed.;y
No. ��Gl� FEE U : � �'7
COMMONWEALT14 OF MASSACHUSETTS C
Board of Health, /YID/ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair/ Upgrade ( ) Abandon( ) an individual sewage disposal system
at C `e A.—t: t h �`� /.b R i2 as described in the application for
Disposal System Construction Permit No. S dated
(moS_
Provided: Construction shall be completed withiin_thxz@-years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat / dl - Board of Health