HomeMy WebLinkAboutApp-Permit-ComplianceNo. / —.22— FEE
THE COMMONWEALTH OF MASSACHUSETTS
Yarmouth MASSACHUSETTS
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Application is hereby made for a Permit to Construct ( ) or Repair ( 35 an On-site Sewage Disposal System at:
Location Address or Lot No.
¢�
Owner's Name, Address and Tel. No.
43 Meadow Brook Rd pow
Mike Grady 778-0105
W. Yarmouth MA Lo't _
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
W.E. Robinson Septic Service
P.O. Box 1089
Centerville-
Type of Building: ~
Dwelling No. of Bedrooms 3 Garbage Grinder (nq
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 sand
Natureairs or A�ter!t�pump & fill in old cesspools &
�(w�
ins Tnew ga an Tbox
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 been issue th' oard of Healt
x
Signed S —,?—!R �—
Application Approved by
Date`
Application Disapproved for the following reasons
Permit No. :Z� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Yarmouth , MASSACHUSETTS
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THIS IS TO CERTIFY that the On-site Sewage Disposal System installed( ) or repaired/ replaced (x ) on
,Z- 7--Fln by W. t. Robinson Septic Sery. for Mike Grady
at 43 Meadow Brook Rd has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ?6— 2_ dated
``2 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 7 • / Inspector -