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No.� / / FEE
COMMONWEALTH Of MASSACHUSETTS
07•/- YARMOUTH HEALTH DEPT. U
a
Board of Health,l jA ROUTE 28 , ALIL
APPLICATION FOP, DISPfflAT'TRYNWftUCTION PERMIT
Application for a Permit to Construct( ) Repair(.,), ) Abandon() - ❑ Complete System ❑ Individual Components
Location f
Owner's Name &A �Jriz4
Map/Parcel# -► 43C9,
Address �-e ee,I`
Lot#
Telephone#
Installer's Name
Designer's Name,
Address . ]0 114-7e?!/7
Address
Telephone# 7 1
1Telephone# --
Type of Building 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��J l gpd
Plan: Date fj 1 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ?,::I— rr P/,4ry
The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not la the system in operation until a Certificate of Co li hce has been issued by the Board of Health.
Signed Date /7/
No:. ~ FEE
COMMONWEALTH OF MASSACH S13TS
livl
d $oarOf Health, E
CERTIFICATE, Of COMPLIAN
Description of Work: ❑ Individual Components) ❑ Complete System
11 The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Graded ( ),Abandoned O '
by#_
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and th
,proved design plans/aspbuilt plans relating to
application No. �.Z `/'3 .7, dated Approved Design Flow (gpd) fir'
Installer O ` r cam,
Designer: t`% Inspector:, Date.
f
The issuance of Ampermit shall not be construed as.a gu a antee' that a sgstem will ,function as designed
No. D� �lJ� (. i�77�1�� FEE
COMMONWEALTH, Of MASSAC14USETTS
Board of Health, , Md.
DISPOSAL[. SYSTEM CONSTRUCTION PERMIT
Permission is he by ranted to•' Construct( )` Repair(�grade( ) Abandon( ) an individual sewage disposal system
J.
at T (CGt'C` V as described in the application for
Disposal System Construction Permit No., dated /'"
Provided: Construction shall be completed within
tt�f tfie date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 2 --Board of Health