HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 28
No. �7 �� SO. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
, MASSACHUSETTS
FEE
ckVyjjra#tan for Pisposal Sgstexit (gons#rurtion 1hruttit
Application is hereby made for a Permit to Construct (X or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot No.
3-6
Owner's Name,ddress and Tel. No.
�DAy,1 cL. � I�ber- �n
rvlc iFL-1) (IT(ITAL. Zos?e
Installers Name, Address, and Tel.No.
Designer's Name, Ad ress and Tel. No. 7
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Design Flow !4 d gallons per day,
Garbage Grinder (A;�
No. per Persons Showers ( ) Cafeteria ( )
Calculated daily flow 487 gallons.
Plan Date —3( 2_<�_ 7 Number of sheets Revision Date
Title S ITh- 0 A„ 4 D.4,-1 t r d h ea.. ehAiN413Fc 1 cr 3 2- --sem 1 f�
Description of Soil YYtI d Jt!4 3
Nature of Repairs or Alterations (Answer when applicable)
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 has be suedtby this Boar of H�x1� �t/ n/ �-/ v
77 X_� 7 Y
Signed
Application Approved by
Application Disapproved for tie following
Date
Date 6 � ..9 7
Permit No. 7 ?� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
JA ,rYnn') 0 1� , MASSACHUSETTS {
Certifira#e of (foutylianre
THIS IS TO CERTIFY, that the On -sl Sewage Disp'osal••System installed ( ) or repaired/ rep ( on
by C'is forC�i�t��Z..
at Z ct —2-;' 3c-*) 0y Sfi 7 as been constructed in
accordant with a rovisions of Title 5 and the for Disposal System+ Construction Permit No. 907 / dated
7 . 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 system will function as designed. This
Certificate expires on
DATE /.2 %' % Inspector'