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COIM�IOI� I L 1 OF MAQQA4 IIIJSE7TS
YARMOUTH HEALTH DEPT.
Board ofHeallh, 1146 ROUTE 9A . M.
APPLICATION FOR DISPOSAR�� l �'TWHIMTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - omplete System ❑ Individual Components
Location`
q Iva i'tiL`i 1 hOwner's
Name til r L' y '(
Map/Parcel# f )
Address (,(, 6 C)
(V �-'r✓ 7r
Lot#
Telephone# 3&t]-6/:�-`)
Installer's Name �_) l i � y �-�' �'�s f ,
Designer's Name
Address 3 /? /lids �.�
Address Cj3� ti
�r / ✓1 S
A ti �
L /F
Telephonet6 J '7 3 '7
Telephone# .Sc- ,� fo;' - Lt S
Type of Building 22 Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Plow (min. required) % gpd Calculated design flow %L Design flow provided gpd
Plan: Date Gy' S `_ 4]Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Sp 0 S -O j "C � 9) x�n
The undersigned a to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t t to lace U/rlsy�ste`n tett until a Certificate of gomp ' nc as been issue by the Board of Health.
Signed ,. L/� Date
No. P r ea �. d t , E FEE I'r.'� G✓..0
COIMMONWTALT11 OF MASSACIIUSFTTS®,�
f �. /`
Board of Health, "�� i • +•' . ^ , MA.
GERTIFICA T OF COMPLIANCE
Description of Work: ❑ Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by )C J l /S- (� cc,?�-O F''s t c c -r L) ,
at lllorr6 to N r h f x" i'. ` .,S C''t--s �11?
has been installed in accordance with the provisions of 310 CMR 15.00 (Title . and the ap roved design plans/as-built plans relating tc
application No. 06 - "'�6 , dated .. -i°O'-�5Approved Design Plow "J (gpd) ;ar�r; ,�, , 6rt��y K,
Installer �`01c ,Afit;. r/ 0, V fie'.-rC C��.'.n _ ^c'.�r4 ri �. ,. �ar� �j,7t,/41v.✓ ,ilvtid%'(
Designer: 4.^fil"`rii49 X.. Date:
The issuance of this permit shall not be construed as a guarantee dr. t the system will function as designed.
No.0 e16
COMMONWEALTH OF MASSACHUSETTS
Board ofI-kalth, A -,/C, i �`"''�-�^ � , AIA.
U/
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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FLV),tr d
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon ( ) an individual sewage disposal system
at Ll 69(a VC/)r-/') f r) C7 / )`7 ��'` i car �� �,%r-�-r-r as described in the application for
�,,. pp
Disposal System Construction Permit No. '%'t� `` l �� ,dated _7 "" A) f,S
Provided: Construction shall be completed within tEUEe-yearsr> of the date of this peCmit. All local condidans must be met.
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Farm 1255 Rev. 6/98 A.M. SUIkIn Co. Boston, MA Date 2 Board of Health -f'_ f,. � , rLrc✓° K!„„r°"'s;.c.,�^"
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