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No. PEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth, NA
APPLICATION FOR DIS'OSAL SYSTEM CONSTRU t ' , IT
Application for a Permit to Construct( _ ` -rade( Abandon 0 Complete Sys,m. Individual Components
Location -7;L /rl0A S't" PoLr Owner's Name 7) Qa f
Map/Parcel# Address '7,)— c?‘A. Fe)Lf
Lot# Telephone# �s- d -
installer's Name t� �• k vf74 Akeem Designer's Name
Address I Cis�I($tt/t,C 5J flA0 Address
A)
Telephone# 4."--dg , -77(, • 3(fl-q Telephone#
Type of Building Lot Size sq.ft.
Dwelling—No.of Bedrooms Garbage grinder( )
Other—Type of Building No.of persons Showers O,Cafeteria()
Other Fixtures
Design Flow(min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Destaiption of Soil(s) tier)
Soil EvaluatorForm No. Name of Soil Evaluator Date offEvaluation /}�,
DESCRIPTION OFREPAIRSOR ALTERATTONS 4 PP tA LI II ..e---- t -J--0p r t
T°11116 ' 4b 0r. Cesspool (s)
.The undersigned agrees to install the above described Individual Sewage Disposal System In accordance with the provisions of TITLE 5 and
further agrees of to place the ystem in o erasion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 6/'Z,/Zd 2a,
inspections _
5 Flt 9 ,1 rt-,qi : „ r - Old 66-AA/N,.
SbD QC 22 $3COMMONWEALTH OF MASSACHUSETTS
�fr, Lwrl5rz_
Board of Health, Yarmouth, ,WA
CERTIFICATE OF COMPLIANCE cJ "• C y
Description of Work: 0 Complete System 0 Individual Components t`r CG 1
The under igned hereby certify hat the Sewage Disposal System;C nstructed Repaired() ()Upgraded Abandoned() •t 4
by: / -CCU 5 ()- ( - ae M0•ir ( Nr 6#1.< 12u€c.
St
at: '7 a. M .13-Lt K ST 01”G /9
has been installed in accordance with the pmvts pf 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application No. ,dated 1 L . Approved Design Flow (gpd).
Installer:
Designer: r -mwo' Inspector:__ [s--N-'‘. Date: S ---� 2__
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS / I
Board of Health. Yarmouth,MA e t_ c G ti-P4,
DISPOSAL SYSTEM CONSTRUCTION PERMIT G.",�
Permission is he y rant�o; Construct() epair Upgrade() Abandon() an individual sewage disposal system at
'01- as described in the application for
Disposal System Construction Vomit No. ,dated (l v ••
Provided:Constructiononshall be completed within three years of the date of this permit.All local conditions must be met.
Date J I�- - �01rd of Health ��C/J1'•s""_l