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COMMONWEALTH Of MASSACHUSETTS
YARMOUTH HEALTH DEPT. i
Board of Health, 1 a da RQ t�r2 , MA.
APPLICATION FOP, DISP®SAT-0 ''�,T CTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location AJ rTh t Sv S;
Owner's Name h
Map/Parcel# &H '7 Q
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Address ,''n Iva
Lot# Fe
Telephone# 3 4 y —
Installer's Name
61-61�V rs C61-10-
Designer's Name Y/. ,7 /7 /,�,j /-jL
Address j n j4,(,npW
AV'
Address �o �/ S f Lp j Ply y7 1 S' vyy
Telephone#
Telephone# 3 r—S - d H
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) 3fj�'� gpd Calculated design flow Design flow provided =_� gpd
Plan: Date Number of sheets Revision Date
Title Lai
Description of Soil(s) S-P e �c� /
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
S'e-e
The undersigned agr s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t po lace s m ' ' ation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date O "'--� —zz
Inspections
No. ��J `�®l�lll` O V'V' EALT1 t OF MASSA'1,�L7ti SETTS FEE � /
Board of Health,
P-t c 7'1'i MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) L'TComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (1j-'Abandoned ( )
by: &L-L-_ /,-S ;6 �S
at Sa VC., Git:� Cao41 c-
has been installed in ac ordd\ance with the provisions of 310 CM 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No. Q :% , dated /Q � proved Design Flow tq (gpd)
Installer F✓ I I t S TkF f-S, SJ • CO,
Designer: 1 � P Inspector:
The, issuance of this permit shall not be construed as a guarantee that the tyltern will function as designed.
No. _ �.� L / -S FEE W
C®MMONWEALT14®F MASSAC14USETTS 4 ��G
Y"
Board of Health, (./�► lrnd� � T �,MA.
DISPOSAL SYSTEM CONSTRUCTION
IIJCTIOT PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at a"S a- h/&/- -k1 %'' ti I ll "C" ,!fit 02nC ,w as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within t +e -�ears of the date of this pe it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin`co. Boston, MA Date 6- 71Lrd of Health l �f