App-Permit-ComplianceYARMOUTH HEALTH DEPT.
°No.27`161146 ROUTE 2 Y 8 FEE , 000
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CO�Iio' ONWYMP WMMV11USFTTS
Board ofHealtlt, 'MA.
APPLICATION FOR DISPOS L SYSTI-M CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeM/Abandon ( ) - ❑ Complete System f] Individual Components
Location
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Map/Parccl#
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Address S
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Lot#
Telephone#
Installer's Name
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Designer's Name
Address '-3
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ress
Telephone#(y.2--�
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Type of Building Lot Sire sq. ft.
Dwelling - No. of Bedrooms 74 o 2 e Garbage grinder j ig
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
other Fixtures
Design Plow (min. required) L% gpd Calculated design flow Design flow provided _� 75 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS ORALTERATIONS
Name of Soil
Date of Evaluation
1 '
The undersigneda o'in
agree s the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
farther agree, not pl m ' o a on until a Certificate of Compliance has issued by the Board of Health.
Signed Date e.� ",�2fs7
8
Inspections
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No. 1?7-/ 0 FEE `"1 CJC:, J
COMMONWEALTH OF MASSACHUSETTS �,r X071
Board of Heahh, _�j 4 A-144 U 1—h , MA.
(ERTILICAi OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System o
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( 0� Abandoned ( )
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at - �. ^''�, H i.. .!1 ] F f ..c,n.. ..--P^°.i �"% r' ' ✓1 bri""7h,„.'-'pr ,�'d-•, ,<I
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the proved design phis/as-built plans relating to
application No. "��� dated ^ "irJ "� pp,/„oCctgl Design fif I"T �� pd) a 6'
Installer t\ 9
Designer: ('f4°^._%._ r A_uy brspector: ..°tom^' V— ""/ Date:
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