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Board of Health, YARMOUTH HEALTH,�T.
APPLICATION FOR DISP®SM MTR"t, CTI®N PERMIT
for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System 9Individual Components
Location
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Owner's Name SL►�{AT
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Map/Parcel#
a s -7Address
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Lot#
Telephone# `
Installer's Name (jAp&,
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Designer's Name NIA
Address ed
C��rS'` M i4p(s5
Address
Telephone#
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Telephone#
Type of Building R EY1 Z) WT 1.4 L. Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
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
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 10574LL 3; " SPC ----IA(, w 17'0 Aj<-a 00 dti646tCi Gr ES RWL
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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 thesystem in o eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 10-01-1-7
Inspections
No. I��3 FEE ✓ J
C®MMONWFALT14 OF MASSAC14USETTS Ck:j� 6 G ID --,7-
Board o Health,
f ��d_i � ; MA.
CERTIFICATE Of COMPLIANCE �j � 18
Description of Work: Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at
has been installed in acco dance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow (gpd)
Installer
Designer:nspector: Date:
The issuance of this ermit shall not be construed as a guarantee tha a tem will function as designed.
No. 4iD c /- 6 g f_3 C -A e V" I D FEE
COMMONWEALTII Of MASSAC14USETTS C 6 Z
Board of Health, � , MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair() Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 144Z L'Z r—a 1� Arte as described in the application for
Disposal System Construction Permit No. £, ,adated v, .
Provided: Construction shall be completed within three years of the ate of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health g a 2
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