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1146 ROUTE 28
No. SO. YARMOUTH, AAA 02664 FEE 00
/kMMONWEALTII OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOP ➢ ISPOI l SYSTEM CCONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ), Upgrade( -<Abandon( ) - I_TC;omplete System ❑ Individual Components
Location y'1 LJ
Owner's Name
Map/Parcel# M A IZ 7W 5V
Address
Lot#
Telephone#
Installer's Name >
Designer's Name
Address
Address
Telephone# �,
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 33D gpd Calculated design flow _31T-/ Design flow provided '.3s / gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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/Jto place the systemAeration, until a Certificate of Com fiance ias been issued by the Board of Health.
$igned .Lc2 IVY (�1 AA44349IN Date �
111spections
3
No.
COMMONWEALTH Of MASSACHUSETTS FEE
Board of Health, , MA.
C ERTIFICATCOMPLIANCE
Description of Work: ❑ Individual Component(s) CTComplete System
The un ersigned hereby certify a the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( , Abandoned ( )
by:
at
has been installed in accord with with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application o.� ` 6, eSl c Approved Design Flow i (gpd)
Installer
Designer:
The issuance of this permit shall not
No.
AALUIJ�sPector: (!! �Date: fT
be construed as a guarantee that de system will function as designed.
00
FEE 00
COMMONWEALTH Of MASSAC14USETTS n
Board o Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran((tted to; Construct( ) Repair( ) Upgrade (Abandon ( ) an individual sewage disposal system
at 4 `� (s (i l'9'l�'YJ� = as described in the application for
Disposal System Construction Permit No./ 7 `A 6 , dated S 6
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston; MA Date goard of Health /
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