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��� � Board of Health, YARMOUTH HEALI DRRT.
1146 ROUTE 28
APPLICATION FOR IUrISPO9AkY.9fflR* N UCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System O Individual Components
Locatio
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,f�l/1 Owner's Name %�j�%f!/d Cj 1� • (✓
Map/Parcel# /47
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Address V2,
4/D . �/fA/ e. ,PI
Lot#
Telephone#
Installer's Name
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Designer's Name
Address 2—
- / y
* Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)gpd Calculated design flow
Plan: Date--% < Num er of sheets
Title N��t/ I— r &Zo! ,�..�is
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
No. of persons
L_
Lot Size l S!� SQL �7sq. ft.
Garbage grinderAW
Showers ( ), Cafeteria ( )
Design flow provided -99-/— gpd
Revision Date
Date of Evaluation A2 -ted e,-- 9%
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 lac` thea e n until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /O ���
Ins ccttions
/i01 -e/
No. G f '� � COMMONWEALTH Ei�YLT1t1t ®F MASSACHUSETTSFEE
4 f01
Board of Health, 01W , MA.
CERTIFIC& OF COMPLIANCE
Description of Work: ❑ Individual Component(s) .2 -Complete System
The undersigned hereby_ certif that the Sewage Disposal System; Constructed (' ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: l
has been inst<111ed inaccordan a with the provisions of 3 CM 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. !%�/ Z -dated �l0_ -d Approved Design Flow (gpd)
Installer �(� 1 &,ttii,
Designer: ��-�J�f� Inspector:Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, ✓'"""' MA.
l�
DISPOSAL S YST CONSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 11410i, If- A as described in -the application for
Disposal System Construction Permit No. , dated /0
Provided: Construction shall be completed within tkt " fs `of*e date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Cnadeslown, MA Date �D 1 pard of Health( L�2