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-151,177-Q-21-DOVIG4 .
• No. ftk3SW,2.1 ' t22
F(�F:
Z -IDS COMMONWEALTH OF MASSACHUSETTS APR 2 7 2021
Board of Health,Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PE�.Mi1- T.
() LTH DEP
Application the a Permit to Construct Repair()Upgrade bandon()-❑Complete System 0[Individual Components
Location AS- Ci 1W E.},Z'L(. 4 q r L Owner's Name e.;b r,-i 64,.-t.s. g 41-__I
Map/Parcel# i` cl 9 Address 1cr Q E k *11 G 4/ C.V„r,,,
Lot# 1 Telephone# J /)
Installer's Name PIC /�4� /t,sJ l Designer's Name -i�nhe'7 ii.7 i,
Address a/3 ! X,,vK- Ad Address a91 C /r,.i^ tr' L_, -/ ,g/'ew_1A✓
Telephone# s(O - 7 (6e1A^� Telephone# CC t. aG7,�—`I-91
Type of Building `l�V I c.['// .mot S. / Lot Size �,? S�q? sq.ft.
Dwelling-No.of Bedrooms Li Garbage grinder( )4i U
Other-Type of Building No.of persons Showers(),Cafeteria()
OtherFixtures
Design Flow(min.r uired qi-tCS gpd Calculated design flow 415G. Design flow provided 11 d8Pd 4-,s--40fief
Plan: Date 7 .. Numberofsheets ( Revision Date
Title C't tAtf�L ti inn
, /� / �j
Description of Soil(s) ,.rr ,'� �c�-// At'L+�qGlL���� v c %-s_
Soil EvaluatorForm No.P,'T" �Jc Name of Soil Evaluator M'd JViIL Date of Evaluation e2//dal
DESCRIPTION OF REPAIRS OR ALTERATIONS _i. ,k/ 2 vim, 6 411-7 0i-2 Gt,-[�)C,J
The undersigned acre to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton to t d sr.in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed - Date ry114/-z.)'
Inspections
No. ` ':i 2\ 30-2 FEE T 0
COMMONWEALTH OF MASSACHUSETTS Ni>d S " ate-- Llf-
Board of Health,Yarmouth,MA 1• 44-19t
CERTIFICATE OF COMPLIANCE 2 ' -it6:0_44
—c'�
Description of Work: 0 Complete SysteiILndividual Components
The unde `ed heretly certify that the Sewage Disposal System;Constructed() Repaired() Upgraded Abandoned()
at. C' W� t S owl tha
has been instal " r with the pro "ions f 3 0 CMR 15.00(Title 5)and rov design plans/as-built plans relating to
application lIi�kQ dated a F►Z . Approved Design Flow r (gpd).
Installer: /v r`/�
Designer: �t9 c S Inspector: pl �r T 1 C11 i
(The issuance of this permit shall not be construed as a guarantee that the system will function as designed. R(,.,\V,.
No. C:2_1' • 2:2-- FEE 1`o ---
COMMONWEALTH OF MASSACHUSETTS
Board of Health,Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissi t�bereby ant Q onstruct() Repair() Up ade Abandon() individual sewage disposal system at
S n��j as described in the application for
VKIL //
Disposal System Construc" n' ermitNo.'dated �� 1.
Provided-Co ction shall be completed within three years of ate of this permit.All local conditions must be met.
Date � 7jf Board of Healt
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