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App-Permit-Compliance
) No. 4)1(k 1Z FEE r. .i COMMO WEA LT14®F MASSACHUSETTS YARMOUTH HEALTH DEPT. Board of Health, 1 ..0 FIO TE 2 MA. APPLICATION FOP DISP®S : V ' 'f�ff1JCTJ®N PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components LocationZi Owner's Name Map/Parcel#T Address Lot# Telephone#�l� Jnstaller's Name Designer's Name Address L �X Address Telephone# Telephone# Type of Building Dwelling - No. of Bedrooms Other - Type of Building 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 DESCRIPTION OF REPAIRS OR ALTERATIONS /(WLaC No. of persons Lot Size sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to of to place the tem in 9peration until a Certificate of Compliance has been issued by the Board of Health. Signed �J 9/_Lb /% H �� Date �© Inspections No. COMMONWEALTH EALTH ®F MASSACHUSETTS FEE Board of Health, Lh z.�ll�i�l,h MA. CERTIFICATE Of COMPLIANCE � Description of Work: Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired V Upgraded ( ), Abandoned ( ) by: at i has been installe�iin actor a e with the rovisions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated/� .ti `� Approved Design Flow (gpd) Installer5!// �GCGG��GJ�! Designer: `r Inspector:i� �'� Date: 1 V e-- V r The issuance of this permit shall not be construed as a guarantee that the system 4Wfunction as designed. No._�'/ ( K CGi-C FEE OMMONW EALT14 OF USETTS Board of Health, L. i j //�/�f l��t MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission ishe:,L�Zranted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at �2 j& aim im 1. a i )M6L & as described in the application for Disposal System Construction Permit No. /�, dated /U Provided: Construction shall be completed within three years of the date of th6perm't. l local condido ss must be met. 4 Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �� Board of Health / /�