HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 28
R No. SO. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
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Application is hereby made for a Permit to Construct ( ) or Repair ( an On-site Sewage Disposal System at:
Location Address or Lot No.
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Owner's Name, Address and Tel. No.
Installer's Nam , Address, and Tel.No. a4. -X-- d"2._,7'-
Designer's Name,A.ddres_s and Tel. No.
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Type of Building:
Dwelling No. of Bedrooms �i3 Garbage Grinder
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow J gallons per day. Calculated daily flow :531.2 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
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 been . ed by this Board of Health.
Signed Date �f
Application Approved by Date
Application Disapproved forhe following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
( ertifirate of Gn yltittnce
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ) or repaired/ replace on
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at --) �7 /,���J /� has been dnstructed in
accordance with the provisions of. Title 5 and the for Disposal System Construction Permit No. 4?4;726 dated
�— S _ �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 4_,,
DATE –17 Inspector