HomeMy WebLinkAboutApp-Permit-ComplianceNo.
YARMOUTH HEALTH DEPT.
1146 ROUTE 26
SO. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
, MASSACHUSETTS
FEE �I'�`-�/;�rvy/
cNyjjfirativn for Disposal *Vstera (fans#rurtion Ferntit
Application is hereby made for a Permit to Construct ( ) or Repair (ifj an On-site Sewaee Disnosal Svcten, at -
Loocation Address or Lot No. �/ b�kr�� � � y�$
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Owner's Name, Address and Tel. No. Li — V!7
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eS
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410, lc'iIDU }I
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Installer's Name, Address, and Te1.No.
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Designer's Name, Address and Tel. No. �j�� 3 /.;u
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I ype of Building:
Dwelling No. of Bedrooms Garbage Grinder (Nb
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date _UT/ r5&- Number of sheets Revision Date
Title &.0,PCI S E D :5jeT) a `a &n d i AM 'ZrW- d/ AfA? Z0v DSS
Description of Soil ,5'FA" ,5L_>t
Nature of Repairs or Alterations (Answer when applicable) C/P940b_1Z>-jgr,yq
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 issued by this.Board of ealth. /
Signed C - Date_/_0 "J/ ,? r
Application Approved by
Date
Application Disapproved f the following
4: reasons
Permit No.
Date Issued !F`� — /;g
THE COMMONWEALTH OF MASSACHUSETTS
J5/i�dYl�� MASSACHUSETTS
C iertifirale of YCOMPlialtre
THIS IS70 CERTIFY, that the On-site Se age Disposal System installed ( ) or repaired/re laced ( on
by for-,.Vftl
at` `IZ l'D7'7 d�1/��/40d Ste% --,b# been constructed in
accordance with the provisions of Title 5 and the foi Disposal System Construction Permit No. dated
�d y 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 ✓�