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'No. —/ �+ 1146 ROUTE 28
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SO. YARMOUTH, 0AA 02FEE 664
Board of Health, �T , MA.
PPLICATIO�T FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradekep Abandon( ) - ❑ Complete System ;2 Individual Components
Location �G SNe, Aj.
Owner's Name 1
Map/Parcel# �(� 5lo LAddress6�_5
Atte
Lot# 2__
Telephone# ✓jK . �` -• oZ
Installer's Name 7&4 k�5
Designer's Name
Address / Ub(.. & e$
Address o /big �Gj �
fyw�A
Telephone#723
Telephone#
N
Type of Building —r-fz-d
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. I red gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets 1 Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Date of Evaluation
The unde stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a es to t to pl tem in operation until a Certificate of oqm liana has been issued by the Board of Health.
Signed Date
L b
Inspections
No. ! / COMMONWEALTH Of MASSACHUSETTS FEE
Board of Health, 101Z -T1 MA. G
�T
CERTIFICATE Of COMPLIANCE
Description of Work:�y'lertify
ndividual Component(s) Ll Complete System
The undersigned here that the Sewage Disposal System; Constructed ( ), Repaired X, Upgraded( ), Abandoned ( )
at 1 / 7 t
has been installed in accordance with the provisions of310CMR 15.00 (Title 5) and/the proved design plans/as-built plans relating to
application No. /�6 dated 3 �Z / / . Approved Design Flow �` � (gpd)
InstallerN L�5
Designer: %1 r . GQ� Inspector: Date: 16
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. WU FEE
COMMON EALT14 Of MASSAC14 SETTS
U)m , V&,7a'Let> Board of Health, ; iY MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ( ) Abandon ( ) an individual sewage disposal system
at i� LTJ /'jP as described in the application for
Disposal System Construction Permit No. — &Z dated 3 _22
Provided: Construction shall be completed within three years of the date of this per it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health