App-Permit-Compliance4
No. — r FEE
COMMONW4#�
IA�,Jzh4"e 7-)—1
Board of Hea1M6 ROUTE 28 , MA.
YARMOUTH MA 02864
APPLICATION FOP, DISMSSYSUR CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - A -Complete System ❑ Individual Components
Location
L
Owner's Name
U ( e - Al a 2 CA-; c moo)
Map/Parcel#
t 3 a
Address Hi Qcbb (� le oacL, (La rid
Lot# 15 '7
Telephone#
Installer's Name
L`C
Designer's Name
LL+4,,,d St-Cv;LeS
AddressL
3 ox -7 `,> Ceu ei.n��
Address Z
Lo n w
Telephone#
5n q L( 2-9 c( o Z
Telephone#
pO7 _ 177 7
Type of Building J t 'l
Dwelling - No. of Bedrooms
Other - Type of Building
12—
Lot Size (Cp , cf $ fi sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 o gpd Calculated design flow Design flow provided 3 ci C7 gpd
Plan: Date 3/01/0-7 Number of sheets Revision Date
Title tf - Pe& -,0, i3e-gKA
Description of Soils) G'%'N
Soil Evaluator Form No. Name of Soil Evaluator
ribVUZ Date of Evaluation Z--LI-07
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 ADO 4 a( N'(o Sip 1 � i �Atit�C �- (3 au
r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nto place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 3 -
Inspections
No. ? 9/ FEE
COMMON LT14®F MASSAC14USETTS �
Board of Health, MA. ,•-
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) A -Complete System
The un ' undersigned hereby cer that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (✓Abandoned
by: C A S f C 5, (JC C
�tA &
at Q-'3- ne (nL,1 e. IJP Jlt . f
i
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the pproved design plans/as-built plans relating to
application No. 40 " `/ dated Q -7. Approved Design Flow _(gpd)
Installer c�W C ✓` t L
Designer: At " i.AdKJ 5-cl:.ts.,e InspectoDate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 07- r�'Gt�-!
Board of Health, L,.; Qd L%1% ALA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE��
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( Abandon ( ) an individual sewage disposal system
at q 2 -� e o-cL
as described in the application for
Disposal System Construction Permit No. 7 C71 dated Q 7
co k1W
Provided: Construction shall be completed withinqhF4&-ye s o�the date of thisperm{t. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ~677Board of Health /