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No. LU— ` FEE
Board of Health, 1146 ROUTE 28 AIA.
YARMOUTH, AAA 02664
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
plication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location] i t •
Owner's Name—,/—,44&— e'%d AA, -f>
Map/Parcel#/ — j00
Address
Lot#
Telephone#
Installers Name 1
Designer's Name
Address y ' IQ �! v '
Address
Telephone# ,, C�//�j_ �'�
Telephone#
Type of Building I`a Lot Size sq. ft.
Dwelling -No. of Bedrooms + �` �C - VlFj ✓ Garbage grinder.0
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (Tin. required) �s� gpd Calculated design flow �7 Design flow provided��3� gpd
73
Plan: DatA Number of sheets 2- `�� Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -"�w 157 �?A(' �¢x1 /�✓t — �% lL� �J
JF
The undersigned ees to ' the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to of a the system in operation until a Certificate o Com liance has been issued by the Board of Health.
Signed Dates /��
Inspections
No. / ` _ 9 �C of 7 , I% a fi!/ it FEE
COMMONWEALTH LTH OF MASSACHUSETTS
Board of Health, Y� "� u "� , MA. o�
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The unrsigned he;e_,;�ertify that the Sewage Disposal System; Constructed Repaired Upgraded ( ), Abandonedby:l' ), N!
at KC/ Lbe!je
has been installed in accordance with the provisio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application. 10 — b dated Approved Design Flow (gpd)
Installer / •_M7 X,_/ L-, , , ,7
Inspector: - l-2� '--r Date: -07 _
The issuance of this permit shall not be construed as a guarantee thfit the system will function as designed.
No. jy —9d FEE J—�I
COMMONWEALTH OF MASSAC14USETTS IW
Board of Health, r `'` / MU MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at :3(/ UP./4 W% as described in the application for
Disposal System Construction Permit N010 "%p , dated �l a
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
11 U
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChatleSiown, MA Date�-1 /_L / Board of HeaAi�il l � ,
V
