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Board of Health, 1146 ROUTE 28. MA.SO. YARMOUTH, MA OMM
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Type of BuildingLot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
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
Design flow provided gpd
Revision Date
Date of Evaluation
The under ' ed agrees to install the above described Individual Sewage Disposal ystem in accordance with the provisions of TITLE 5 and
further a s o e th to in operation until a Certificate tom as been issued by the Board of Health.
Signed Date Y
Inspections
No. � COMMOl� V'1' EALT14 Of MASSACHUSETTSFEE�CJ
Board of Health, 1 yt tb MA.
CEPITIFICAfE Of COMPLIANCE
Description ofWork: /Individual Component(s) ❑ Complete System
The under sg ed er by c r((ti��fy t at th Sew ge is o System; Constructed ( ), Repaired ( ),Upgraded ( ),Abandoned ( )
by: / D
at
has been installed in acc rdapce with the �dR
'ons o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application v�— {7, datA)proved Design Flow (gpd)
Installerf
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gua'rrantee that a system will function as designed.
No. CJ ✓ J�"" / //` FEEr
COMMONWEALTH OF MASSACHUSETTS
Board of Health, t 't MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( t ( Upgrade ( ) Abandon ( ) an individual sewage disposal system
at IL/ i' N I V - )[,i I 8_J as described in the application for
Disposal System Construction Permit No. 61-) J - dated
Provided: Construction shall be completed within t_-.l�s of the date of this permit. All local conditions must be met.
P p ,
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / Board of Health
.Telephone#
Designer's Name
Address
Address
Type of BuildingLot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
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
Design flow provided gpd
Revision Date
Date of Evaluation
The under ' ed agrees to install the above described Individual Sewage Disposal ystem in accordance with the provisions of TITLE 5 and
further a s o e th to in operation until a Certificate tom as been issued by the Board of Health.
Signed Date Y
Inspections
No. � COMMOl� V'1' EALT14 Of MASSACHUSETTSFEE�CJ
Board of Health, 1 yt tb MA.
CEPITIFICAfE Of COMPLIANCE
Description ofWork: /Individual Component(s) ❑ Complete System
The under sg ed er by c r((ti��fy t at th Sew ge is o System; Constructed ( ), Repaired ( ),Upgraded ( ),Abandoned ( )
by: / D
at
has been installed in acc rdapce with the �dR
'ons o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application v�— {7, datA)proved Design Flow (gpd)
Installerf
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gua'rrantee that a system will function as designed.
No. CJ ✓ J�"" / //` FEEr
COMMONWEALTH OF MASSACHUSETTS
Board of Health, t 't MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( t ( Upgrade ( ) Abandon ( ) an individual sewage disposal system
at IL/ i' N I V - )[,i I 8_J as described in the application for
Disposal System Construction Permit No. 61-) J - dated
Provided: Construction shall be completed within t_-.l�s of the date of this permit. All local conditions must be met.
P p ,
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / Board of Health