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COMMONWEALTH OF MASSACHUSETTS
YARMOUTH HEALTH DEPT. f.
Board ofTlealll),j 46 RAl ITF 98 MA.
APPLICATION FOR DISPMX'"�S" 'tvl tMgti RUCTION PERMIT
Application fora Permit to Constuct( ) Repair( ) Upgrade( ) Abandon( - O Complete System ❑ Individual Components
Location
,
Owner's Name lit- D
Map/Parcel# �rj " _ �' �`i� Qy�
Address
Lot#
ill l
Telephone#
Installer's Name
�, Y
'
Designer's Name
Address2j?
,
Address
Telephone#
.��� �6Z�
Telephone#
Type of Building Loc Size 115W1 / sq'. ,f/t.�,,�
Dwelling - No. of Bedrooms Garbage grinder (i(�
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided 3�G • pct
Plan: Date Number of sheets �, Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soi Evaluator of Evaluation
107-1_ /
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 t lace/t/yp s �{��/pJ on until a Certificate off C/ompI* ce has b�e�etJ issued by the Board of Health.
Signed � i%'�" ' Date �l �f/
Inspections
No. FEE
COMMONWT_LrlALTII OF `,SSAC-IIUSI'..TTJ
Board of Health, % JL l)�' ' , JIIA.
LI RTIFIC ATt OF Q OIM.�PLIiC 1
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned ,hereby -certify that the Sewage Disposal System; Constructed ( ), Repaired (), Upgraded ( ), Abandoned ( )
by: q g
at ', �,.. �'/^a�z-j !( t'`r'(' ( r) / 1. f,''' G:%✓'/ ��✓",
has been installed it accordance with the provisio is of 310 CMR 15.00 (Titld�) and the a>proved design plans/as-built plans relating to
application Nc '- dated p0 _.� Approved Design Flow �. gpcl)
Installer'`'
Designer -5✓� f4rt-'%"—` Inspector: i(!- -'C-i!L-C.f� Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No.l ca°" (� FEE
CO1M[MONA EALTI OF 1MASSA IIUSETTSIA
G� Board ofllealtla,-%�OU� AM.
DISPOSAL SYST SII CONSTRUCTION PI --R 'IIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon ( ) an individual sewage disposal system
��r,,r ,
at � i i. -'c . /'Z/' I`1 4 UJ %ti r. as described in tete application for
Disposal System Construction Permit No. (Z , dated/_IC _/�f 00
Provided: Colistruction shall be completed within three years of the date of this pe tett All local conditions to tst�bee met.
Farm 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date _�/_/ /( Board of Health
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