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YARMOUTH
Board of Health,EA
11 � ROUTE 20 EP,
&,*PLICATION FOP, DISPOSANVM�T-OMWWWN P M
Application for a Permit to Construct( ) Repair( )- Upgrade C<Abandon() Complete System ❑ Individual Components
Location j4 y�7i� &9
Owner's Name ft,t C n i -y A4 Lvt
Map/Parcel#
Address 3 Lj 'eS
Lot#
Telephone# .2 �R- l —&"4f 3 S1- (i
Installer's Name 1
Designer's Name & ld LO o -a > �L
Address—F
Address `p, 0� O'S u ciV_
Telephone# 3 —G
Telephone# 77 S'--- 5�7CG
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms b4oGarbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date 7 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS S t �;OiU(�'!L QfX
Date of Evaluation
W
The undersigned agr s°to install the abo a described,Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
-� further agrees to o e t until a Certificate of Compliance has been issued by the Board of Health.
;Signed Date
Inspections
COMMONWW LTII Of MASSACHUSETTS
Board of Health, `� MA.
CERTIFICATE Of COMPLIANCE
FEE 5V7f
(W (/70 -'*! /6F 7 -7,
Description of Work: ❑ Individual Component(s) -tlTomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(-)', Abandoned ( )
by. �= i ! S Ica leer S Cc: -,S1• Cc'
at VV, l i Ci
has been installed ij� accoo-r—chance with the provisions of 0 CMR 15.00 (Title 5) an the a roved design plans/as-built plans relating to
application No. dated Approved Design Flows (gpd)
Installer -1 F j _Cep in S Jr� (C IQs
Designer � `�`�) r/ �u i`I�°� `4spector: a— Date: C�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. Q� �/% \ /c%C� FEE
C®MMO WEALT14 Of MASSACHUSETTS -R' I'F 7 7
Board of Healtht
DISPOSAL SYS CIONSTR CTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at �'S l) + �S c ( S} J as described in the application for
Disposal System Construction Permit No. _ , y dated Z
Provided: Construction shall be completed within t ars of the date of this - m All local conc� ,tjons must be met.
/
n Form1 255 Rev. 5/96 A. Sulkin Co. Boston,
YA �' D to / �l oard of /Health U
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