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. e'�/e COMMONWEALTH OF MASSACHUSETTS
Board of Health, Yarmouth,MA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Repair $
on�- Upgrade(1 Abandon(1-U Complete System L Individual/ Components
Location q .P_,Y\i ru 1 i)�\U e Owners Name C i v (t e, ,C'G 'e i
MapiParcel if ( k to / Address l4 inrA a 9,..
Lot* 1 `' // Telephone ti (1- c� j
Installers Name V-1ilke tLt 1 I(�t4 7j� DesignersName'A-'t'eccei' Etworonix.eE.l4,
Address 4 fix- (`/�y{t fl�-� Address t W ecte 6 PACP' .� -r -Loa.�
Telephone#1 N.")R- .2l(e - �-+`( tee.' Telephone ll '1,r14. - c�M< - ` 1 2
Typeof Building i de \AL
\ Lot site tot 10(2 sq.ft.
g � � t
Dwelling-No.of Bedrooms Garbage grinder( )
Other-Ty-pc of Building No.of persons Showers (,Cafeteria()
Other Fixtures
Design Flow(mt requt ) 3 0gpd Calculated design flow (Q(el) Design flow provided t2 gpd
Plan: Date - Numb of shee a Revision Date
Title—PrC)(l( f P 'e 3Lie, .i, VP-ill-re-8 - or T(.1� C)(CAtAV '
Description ofso(t(s) e� g.\Fie\
Soil EahiaiarForm No. Name of Soil Evaluator __t Date of Evaluation
..__„____DESCRIPTION OF REPAIRS OR ALTERATIONS \t\S�l'1\\ L 1„],,O n ��q —,0 (
`` �� ��- � - an ) A. -1C) S( To clvt e_ "e--,
,
.The undersigned agrees to install the above described Individual Sewage Disposal System in accordance rsith the provisions of TITLES and
further ogre u not to place the vstem I peratioo til a Certificate of Compliance has been issued by the Board of He fr.
EgagOKRI
Signed ate
Inspections AU0 1 4 2024
HEALTH DEPT,.
- ------------
COMMONWEALTH OF MASSAC' SETTS u: -- -
Board a/Health, Yarmouth.MA
CERTIFICATE OF COMPLIANCE
Description of Work: p(Cetapkte System CI individual Components
The updersigned hereby certify that the Sewage Disposal System;Constructed() Repaired Upgraded() Abandoned()
by: t-kk ik L 1tiP,Pre-t-A
al: yy�
: S '''e sr.icsOkP_ roil •
has been installed' t ordance with the provisions of 310 CMR 15.00(Title 5)and the approved design plats/as-built plans relating to
application No. 'i'/6,( .dated ''.rS�Qv/ . Approved Design Flow '33�) (gpd).
Installer. (x7 tc G� t�l
Desk: •f i)• Inspector: (3 C2 1A P11,4iffry:4,311Dale s t� /
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health. Yarmouth.MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; �nstruct() Repair,k Upgrade() Abandon() an individual sewage disposal system at
i iV)teJ `3 e , as described in the application for
Disposal SystemConstruction Perron No_ .dated Y•/x'e7s/
Provided:Construction shall be completed - aN f the date of this permit.AU local conditions must be met.
'7
Date ' I C•o2 1Board of Health I