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FEE
YARMOUTH HEALTH WT.
Board of Health,
APPLICATION FOP DISPOMf.' M JCTION` PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location '71
r
Owner's Name
Map/Parcel#
G/
Address
Lot#
Telephone#
Installer's Name
!
Designer's Name �sl
Address 5e
1
Address
Telephone# /
f'� �- ��
Telephone#
Type of Building r Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures ,�// //-��
Design Flow (min. required) gpd , Calculated design flow 4Ei40 Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)�d�9-�
Soil Evaluator,Form No. Name of Soil Evaluator Date of Evaluation
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_W not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �r
r
Inspections
No. mill �7-/ /ELtir L�,�j `/✓l���f FEE
COMMONWEALTH Of MASSACHUSETTS / -3� F G
Board of Health, MA.
CERTIFIC E OF COMPLIANCE
Description of Work: dividual Component(s) ❑ Complete System , ,Q�
The unde ig ed herebcerti�that the Sewage Disposal System; Constructed Repaired (�Upgraded Abandoned
by: �-
at
has been installed in accordance accordance with the' rovisions oPI0 CMR 15.00 (Title 5) nd proved design plans/as-built plans relating to
application No. 101 �� 3 dated KJ .Approved Design Flow�(gPd)
5 �4� ;.r. -
Installer � .X" �
Designer: Inspector. r( Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. O / / aavl - - - FEE *7/1!00
CO9[MONwEALT11 OF MASSACHUSETTS
Board o Health, _, MA.
DISPOSAL SYS CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (V Upgrade ( ) Abandon ( ) an individual sewage disposals stem
at
as described in the application for
Disposal System Construction Permit No. !Q6 /"j, dated '5-�
Provided: Construction shall be completed within,. of the date of this rmit. All to/cal conditions must be met.
Form ,1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date C/ Board of Health VC/qG."