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No. H ,.zo . 0411 FEE
20 — 21 , COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth, MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()RepairgUpgrade()Abandon()-❑ Complete System t4ndividual Components
Location y 3 Lo,,,L-ge S-A--K 11 i 1 I Owner's Name RN.OA A-iZ,b A . E K R 0-CS
Map/Parcel# 1-1 I Li 7. Address C cr}wle
Lot# Telephone#
Installer's Name Ro B .T 13. pop, c . Designer's Name
r
Address 30 t_31‘,A-cs r,4.h{ ..s.L.-n.j ., 04N-RA Address
Telephone# So 8 — Li 1"1 — 2 Q 11 Telephone#
Type of Building Lot Size sq.ft.
Dwelling—No.of Bedrooms 4 Garbage grinder( )
Other—Type of Building No.of persons Showers(),Cafeteria()
Other Fixtures
Design Flow(min.required) gpd Calculated design flow Design flow provided N/A gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil EvaluatorForm No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ABANDa' E)us rrrl G 1=113.3 Ffi° 8 )e, 4A-12.)e-RD Pi P E Line
A Nt i Cc IocikTe Nc.,.3 0133 (}lo Box u.! 12,wG" /3c/a W Go.4pe—
.The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /6 '2 2 'Z D
Inspections 1 Pl. i I il Z
No. \-\ , LD ' v-V-12- j7eog- a 1-ii--y FEE J
COMMONWEALTH OF MASSACHUSETTS NUJ 5,,
L
Board of Health, Yarmouth, MA '
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissi n is hereby ranted to; Construct( Repair K.Upgrade() Abandon() an individual sewage disposal system at
��j ranted
TrITA I as described in the application for
Disposal SystemConstru ion PermitNo. 20 —ZS? , dated 10/17/20 .
Provided. Co struction shall be completed within th ee years the date of this permit. All local conditions must be met.
Date II Li 20 Board of Health
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