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No. '23.21 V 1 Iv o N Jt_ FEE 55,Qo
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COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEMCONSTRUCTION PERMIT
Application for a Permit to Construct()Repair bc.Upgrade()Abandon()-O Complete System$Individual Components
Location f 07 RQcr4 . LD A Owner's Name een LQ yr el
Map/Parcel# Address IO 7 •""' 1♦4.,,Kev 1 P
Lot# Telephone#508'280.. 9200
Installer's Name/ g j(.I 3.cof co.=ne,/_ Designer's Name
Address 3 G3 Loki•+-es po 3.Yaz,„ut ot„, Address
Telephone#5o8 ,� B Of-yo� J iS jMi/YI Telephone#
Type of Building ge6 t cien1 i aI Lot Size sq.ft.
Dwelling—No.of Bedrooms Garbage grinder( )
Other—Type of Building No.of persons Showers(),Cafeteria()
Other Fixtures
Design Flow(min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil EvaluatorFonn No. Name of Soil Evaluator 1 � Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Lowe( .*1e� PY P pe frb,. .lu ep i C. TAn X.
Tb {)u w pp Gho 4 .r !9 f (b)(-. 5 a inches To Cvrrec.T Weaker level
5ept'L rein K. Pec 7.1 fie 5 ;#N sPQ .-wort and leakier fnom J1 D.H.
.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. RECEIVED
Signed aganizik 41>er'r Ou((e-fit Date /'13 23 JUL 13 2023
Inspections
HEALTH DEPT,
No.b Z3 Z\\ FEE 55
COMMONWEALTH OF MASSACHUSETTS C A
Board of Health, Yarmouth,MA isvf. 7; }Z/
CERTIFICATE OF COMPLIANCE CN-e-- T-d10 2 3
Description of Work: ❑Complete System%Individual Components .
The u9ilersignql hsgheby certify that the Sewage Disposal System;Constructed() Repaired IS Upgraded() Abandoned()
by: CD.=f C.
at: !a 7 leevte G A
has been installe in accordance with the provisions o 310 CMR 15.00(Title 5)and the approved design plans/as-built plans relating to
application o dated 7 / • 3. Approved Design Flow+. (gpd).
Installer: Fe t eve co,=rL-
Designer: Inspector ,( j Date:
The issuance of this permit shall not be construed as a ar hat the system will function as designed. J /
No.9J\K'23 2 FEE
COMMONWEALTH OF MASSACHUSETTS r A 1,
Board of Health, Yarmouth,MA I !v 5 e c r J,/z/
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission ii hereby gra ted to; Construct() Repair S.Upgrade() Abandon() an individual sewage disposal system at
1O 7 I< �p 4 as described in the application for
Disposal System Construction Permit No3_12. ,dated
Provided:Construction shall be completed.. of the date of this permit.All local conditions must be met.
Date 9-Atcboard of Health ''/ €._.e_.
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