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2 D -2A-I COMMONWEALTH OF MASSACHUSETTS Q,k20 2120
Board of Health,Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Connsttru \'epair()Upgrade()Abandon()-2(ompiieSte System 0 Individual Components
Location y7c��� w �r6Q/ I Owner's Name Ill:. A'N &USSs A
Map/Parcel it 01 3/y,3 Address
Lot# Telephone#
Installer's NameSpreA LA Designer's Name Down. Cr aj
Address 2 v ritrik �,�� � Address o3 A"'��I�__ -j,�_
Telephone# `5 ��''T Telephone# ``.._ 9 't,4,IIsaw,1
Type of Building OWflt/ Lot Size �[J Y sq.ft.
Dwelling-'�o.of Bedrooms 9 •- 41/1- LAAAAM jam✓T I7 Garbage grinder( )
Other-Type of Building Hoeve, No.of persons - Showers(),Cafeteria()
Other Fixtures -�•-
Design Flow(min.requi�ed)_11 4 gpd Calculated design flow Designflow pro 'ded Li,��-J gpd
Plan: Date 7/7 AC Number of sheets % Revision Date Title I/
Description of Soil(s) �+
Soil EvaluatorFonn No.,St '?��}WV/ Name of Soil Evaluator 1G`. ate of Evaluation 2/I I I 1 fi
DESCRIPTION OF-REPAIRSORALTERATIONS S82- ' •QAdtr1
.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 I Ieaith.
Signed''XI Date__400
Inspections
FEE
No. zoNE ir
dC_--COMMONWEALTH OF MASSACHUSETTS NBC'
Board of Health,Yarmouth,MA / G� 1 ,'✓�^'�
per+ ✓
CERTIFICATE OF COMPLIANCE 2 cJ �.�.'.r
Description of Work: omplete System O Individual Components
�� / '�
The unders. ed hereby certify that the Sewage Disposal System;Constructed Repaired() Upgraded() Abandoned() ,
by: _
at: I ] '-c r,°�,
has been installs 5.m accordance with the prow ions f 3 CMR 15.00(Title 5)and th a ved design plans/as-built plans relating to
application o. 20-2 4r! ,dated IO(157Z0 . Approved Design Flow '7 (gpd).
Installer: uy.�C { h� S
Designer: Inspector: p • Q r Date:
The issuance of this permit shall not he construed-as a guarantee that-the system will function as designed.
No. ZONE' 7Z. FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health,Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is h rit • Cons ct$Repair() Upgrade() Abandon() an individual sewage disposal system at
, kf G as described in the application for
Disposal System Construction Permit No. ZO-2.4 f ,dated/y
Provided: o �ruction shall be completed within t ee years o ,e date of this permit.All local conditions must be met.
Date /O/ T Board of Hea ' _��\-i
411