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tl ' - ‘ A `No`.il \2 72 FEE //6
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OF MASSACHUSETTS
Board of Health, Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
application for a Permit to Construct()Repair()Upgrade()Abandon()- Complete System a Individual Components
�,`1 \` Location \ t5 (Y_Yl„\\ �k` 'j.1 wner's Name G—�G \\Q,c�1 c —
`I1 rY..k, Map/Parcel# „9 18 i ` Address 3 a`�./,Z�`."-4 u Qon& W A`_-'
v Lot# A / Telephone foa7L/ ,..76 0
Installers Name /P/pv �///.'&)t/ Designers Name ���4_[ P, Mat eg Address jf/ L',,/1 V end '71 f t/3 '4'41(Address `a-dt"lJ Csro."V ^
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Telephone it �C,1 r2' S,Is 7 7C' Telephone# co'$)-,1,7 — \ G p 1 X
Type of Building �.er �'�Y1�\A\ Lot Size Alb—if b 77 sq.ft.
Dwelling-No.of Bedrooms � Garbage grinder( )
Other-Type of Building No.of persons Showers(),Cafeteria()
Other Fixtures
Design Flow(min.r quired)) /.j(.{f gpd Calculated design flow '4//f' Design flow provided .1— r gpd
Plan: Date ig3 a I 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 I"E e Lc.) L Ct} -c-2-
.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 �jJ��/
Inspections
N . 2 9,5 2 FEE \\Q
COMMONWEALTH OF MASSACHUSETTS Ai��
Board of Health,Yarmouth,MA Ai
A 2 T de---
Pu
, i Al CERTIFICATE OF COMPLIANCE
c -i1c' r A/.cG tZ .� C• (_ '-1
�_ Description of Work: Complete System 0 Individual Components '
The undersigned hereby certify that the Sewage Disposal System;Constructed() Repaired() Upgraded() Abandoned() C) K
by: // 4".ry A..es.—"
Cil 4-111P 4.
has been mstalle m accoLd ce with the pr o of 310 CMR 15.00(Title 5)and t r ved design plans/as-built plans relating to
application No.c .I 4—I .2 dated (ems,'/ J,( . Approved Design Flow �(.' (gpd). _
Installer:-y',Pi/ n. /It=rP' _
Designer. J Inspector: S .-e►'�1 e`� E't'c___S L Date: C e —) — 1 T G��
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Cr
__No`) L_, 35 L-� ----- FEE110 1p
COMMONWEALTH OF MASSACHUSETTS ~ - —_,
Board of Health. Yarmouth,MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT MAY 0 4 2Oz1
Pern/js n is here y gr,nted t oastruct(p)Repair() Upgrade() Abandon() an individual sewage disposal system a
77 ' / �,/ / as described in the application fee
HEALTH DEPT.
DtsposaYSystemConstruction Permit No. IX:I ? ,dated it/ lif
Provide :C struction shall be completed/w in ee years of the date Jf this permit.All local conditions must be met.
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st DateG Y -( Board of Health J')