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Board of Health, 1146 ROUTE 28 , MA..
. YARMOUTH MA 02
APPLICATION FOP ➢ ISPOSAL SYSTI C®N UCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# /V/ d- oZ /
Address �wMan A
Lot#
n
Telephone# c S0 3 yop —0/avl-
Installer's Name ,
Designer's Name In '
Address
Address
Telephone# s�� ,3
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Lot Size sq. ft.
Garbage grinder ( )
No. of persons oL- Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow t9.30 Design flow provided 3'S�`s�• - gpd
Plan: Date 4�9 D Number of sheets Revision Date
T
Title
Description of Soil(s) ?�,gk)
Soil Evaluator Form No. Name. of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS c 6e o &, 4500Sr -bA Q)(d J L euellS
/ti a ueA C29/y /2.8'1 )(A/
.11
e 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 the sys m in operation until a Certificate of Compliance has been issued by the Board of Health.
:Signed /%JcA cam C:d o� Date i�C�, ,200i
Inspections
COMMONWEALTH OF MASSACHUSETTS FEE 50
Board of Health, Lk em MA.� ,,� 6eq�
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) W"Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (✓Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the 11 a proved design plans/as-built plans relating to
application No. / dated// ' /a � . Approved Design Flow (gpd)
Installer CQ sG/� S ��L�GI /x;7
Designer: ?o2-wff,�' CA `� Inspector: Date:
The issuance of this permit shall not be co/Itrued as a guarantee that the system will function as designed.
No. t/.�-77
COMMONWEALTH OF MASSACHVS ETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
S6
FEE
Permission is hereby granted to; Construct (✓ Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at Y S 7") LI(II)IJIS 1-a evm macr as described in the application for
Disposal System Construction Permit No. -7 % , dated 112.d
Provided: Construction shall be completed within t� of the date of this rmit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date J/ CBoard of Health G- /