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No. Oy�G D 7 / FEE
COMM®NWE-ALT14®f MASSAC14USETTS �
YARMOUTH HEALTH DEPT. w
Board of Healthl 14c ROUTE MA.
APPLICATION FOR DISPORAY '�""�f UCTION PERMIT
Application for a Permit to Construct() Repair( ) Upgrade Abandon() - ❑ Complete System ❑ Individual Components
r
Location Y�
Owner's Name fflatohi 1)17,e "
Map/Parcel#
Addres Q.
Lot#
Telephone#
Installer's Name
Designer's Name
Address'� ' : C . ,G'/�
" " V P�M,
Address
Telephone# ,
Telephone# Ay6--� _
Type of Building
Dwelling - No. of Bedrooms _
Other - Type of Building
Other Fixtures
Design Flow (min. required) _
Plan: Date __� -q-6>
v
Title
Description of Soil(s) _
Soil Evaluator Form No.
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow ljt / Design flow provided
Number of sheets J Revision Date
Name of Soil Evaluator
Date of Evaluation
gpd
The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to not to place the in o er 'on until a Certificate of mp ance has been issued by the Board of Health.
Signed Date De�ll
Inspections
No. COMMON I WFALT14 OF MASSACHUSETTS
Board of Health, MA.
apmricA or COMPLIANCE
FEE
Description of Work: ❑ Individual Component(s) drC- omplete System
The undersignegl hereby certify th t t e Sewage Disposa System; Constructed O Repaired ( ), Upgraded (►�Abangpped ( )
by: - l �'�-rl- .C..,
at . -9cna Ln? - I �
has been installed �accddanwith �th�e;rovisions, of 310 CM 15.00 (Title 5) And,ttheeapproved design plans/as-built plans relating to,
application No.date..Approved Design Flow4`�(gpd)
Installer
Designer:G111%ri,�vJ�- Inspector: ' Date: " ".
The issuance of this permit shall not be construed 'as a guarantee tha the system will function as designed.
No� FEE
COMMONWEA Of MASSACHUSETTS
Board o Health; `¢.' MA. .
.f
DISPOSAL SYST CONSTRUCTION PERMIT
Permission is
<_hereb anl/ted to CLIZ:al
uct( Repair( Upgrade ( Abandon ) an individual sewage disposal �
stem
at
11�as described in the application for
Disposal System Constrdction Permit No. , dated
Provided: Construction shall be completed within t4rree of the date of this permit. All
/local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Boston, MA Date 0.?Aoard of Health �T