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YARMOUTH HEALTH DEPT. 13,976,1 �.
1146 ROUTE 28
NSO. YARMOUTH, MA 02664 FEE
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
, kkyy rativn for Bispeal Sgstrm (gonstrurtion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (�n On-site Sewage Disposal System at:
Location Address or Lot No. ��� Owner's Name, Address and lel. No.
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Installer's Name, Address, and Tel.No. Designer's Name, Address and Tel. No.
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Type of Building:
Dwelling No. of Bedrooms Garbage Grinderijo
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil���
Nature of Repairs or Alterations (Answer when applicable)�W�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance h been issued byis f Health.
Signed // Date��Q�
Application Approved by v � Date
Application Disapproved for te following reasons
Permit No. --�- Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
�lGlf-"'uJ�A' , MASSACHUSETTS
Te>rtifirate of (foxi plian e
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or rep :red/replaced ('_�) on
by S'1CnSS Cc.ra— CC'_S for
at C" k1d )�-3vr ' .r - has. been constructed in
accordancwith the -provisions of Title 5 and the for Disposal System Construction Permit No. --1 _ dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system11 function as desig d. This
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DATE -as 1 Inspector __ — 4%2ey —