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YARMOUTH HEALTH DEPT.Oa
No. `�;;� 1146 ROUTE 26 FEE -50
SO. YARMOUTH, MA 02664 (t�q0
Board of Health, , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (�Abandon( ) - CTComplete System D Individual Components
Location
Owner's Name
Map/Parcel# 4.
Address 15'
Lot#O
ep one#
Installer's Name —
Designer's Na e
Address
Address
Telephone#
elephone# 3
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) _g d Calculated design flow 3310 Design flow provided 357 gpd
Plan: Date 4 1 Ilumber o� sheets ' Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR TERATIONS
The undersigned agrees to ' the bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire s to not to place, t peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date .99
Inspections
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No. 9 COMMONWEALTH OF MASSAC14USETTS FEED
Board
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Board of Health, S1(,�-�/ , MA. �rIMo
CERTIFICATI Of COMPLIANCE
Description of Work: ❑ Individual Component(s) &<omplete System
The un ersigned hereby cer ' that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ("J Abandoned ( )
by:
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. `1 c�- ted ^_ _. Approved Design Flow. 53 (gpd)
Installer /'Jy 0 �L
Designer:and Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.`! .2 7
Permission is
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-��FEE
COMMONWEALTH OF MASSACHUSETTS
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Board of Health, LPMA.
DISPOSAL SYS CONSTRUCTION PERMIT
granted to Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
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Disposal System Construction Permit No.? 9,157 , dated 6 ` o
as described in the application for
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& Board of Health �/" Ce4z
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