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YAHMOU i H HLALTH DEPT.
1146 ROUTE 28,
No. SO. YARMOUTH, MA 02664 FEE p
THE COMMONWEALTH OF MASSACHUSETTS tv
MASSACHUSETTS
'4yfiraxtty for Pieposal Sgotem Gnotrurtion Fermat
Application is hereby made for a Permit to Construct ( ) or Repair (Van On-site Sewage Disposal System at:
Location Address or Lot No. /A�h. 5
Ow er' Na Add r and Tel No.
InstalLi�� :,Address, and Tel .NL��
esi ner's Name, Addre ss and Tel. No. �
�2 .�i(✓2.2-�yZ
,,�e�q���
Type of Building:
Dwelling No. of Bedrooms / Garbage Grindev4eP
Other Type of Building No. per Persons Showers(
Other Fixtures
Design Flow
Plan Date
Title
Description of Soil
gallons per day. Calculated daily flow
— Number of sheets
Revision Date
) Cafeteria ( )
gallons.
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 provision Title 5 of the Environment ode and not to place the system in operation until a
Certificate of Compliance has bee ed i4Bd?,o0ek1(___1�
Signed Date
Application Approved by Date
Application Disapproved ft/the following reasons
Permit No. ( Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
`'x/`I- MASSACHUSETTS
aertt#trate of complinure
THIS IS TO CERTIFY, that the On-site Sewage Dis osal System installed ( ) or repaired/replace) on
2 /9— Fif, by ��L Ofor i 7�//c
at Z.Z 2e%1 S - has b n cons cted in
accordance with the provis' ns of Title 5 and the for Disposal System Construction Permit.No. dated
7- ,Z _. 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 Inspector