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Z j - i 27 COMMONWEALTH OF MASSACHUSETTS ,,= =uv
Board of Health, Yarmouth, MA JUN 0 . 2021
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIS)\ P►'=•IrL 'Al Pr.
- Application for a Permit to Construct()Repair((Upgrade()Abandon()-❑ Complete System ❑Individual Components
Location 11 PO1heQA0 Rei)., t'MOuth(Mk" Owner's Name 4M Ja Ill/j/.ef,4//I.wla /'ff/I
Map/Parcel# 13111ffll 15s Address II POtt o O SRA
Lot# 1'3`5 Telephone# cal.-579••olo'l Fl
Installer's Name 11D i• t) ourv G•D_.-•'�y(�C, Designer's Name�L E na ('iC5
Address s63 W}t14 5 fr4k 5,roputU rnA- Address Q95/1 Crest ady /k y 4:WcNeM,n Mk
Telephone# s'Og-,,y��-$$�7'
Telephone# 56*f•273- 0c57T
Type of Building Q..eSIaifili4 t I _Lot Size di 340 sq.ft.
Dwelling—No. of Bedrooms
3Garbage grinder OjC)
Other-Type of Building No.of persons a Showers(), Cafeteria()
Other Fixtures
Design Flow(min.required) 330 gpd Calculated design flow Design flow provided 33R, gpd
Plan: Date 5/a&(/red)at Number of sheets 1- Revision Date
Title l' fo4Qano as Yar'Mot+ k fork- Of
Description of Soil(s) (YU1cI +0 CDQ.62 Sana net
Se. Plan
Soil Evaluator Form No. Name of Soil Evaluator 0114.4 e./eiflCikle( Date of Evaluation SAO i
DESCRIPTION OF REPAIRS OR ALTERATIONS /UCW D—bbX ) CO2) (1,E 16 G dmJ Cha 4e,rS
IA)t+3J1 . (1 Pxts4-1 nt l 000 &//on Septic-tIC 77AK.
.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.
SignedC....CCDate 5/9 7/R/
Inspections
Na,
' 2.\ . 31' 0
FEE
COMMONWEALTH OF MASSACHUSETTS
6, 6T,�n
Board of Health, Yarmouth, MA
DISPOSAL 'y°EM CONSTRUCTION PER /I -;_____4:4z,c_11:,ersts14....„64.1.:
Permission is hereby granted to; Construct() Repair KUpgrade() Abandon() an individual sewage disposal system at
%c t-.-tePA,Pcas described in the application for
Disposal System Construction Permit No. Z I -/7 1 , dated 1,(e 17,,2-/ .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date G (e)12'2I Board of Health ./-7:3;) 1---k--. 3 I 014-16-' \ 1., .
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