HomeMy WebLinkAboutApp-Permit-ComplianceI
. YARMOUTH HEALTH DEPT.
1146 ROUTE 28
No. 16 '')G6 SO. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
VROVaP T —,MASSACHUSETTS
FEE rL /�""IhP'311
`9W r
at,
cNyyfirattan for PisposalSgstem (fonstrnxttun 1hruttit
Application is hereby made for a Permit to Construct (,< or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot No.
/GjL��$Wd �T7c-rr�
Owner's Name, Address and Tel. No.
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
�3':�n st�d'
k- tl4j _
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Design Flow
Plan Date
Title
Description of Soil
Garbage Grinder ( )
No. per Persons Showers ( ) Cafeteria ( )
gallons per day. Calculated daily flow
Number of sheets
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Revision Date
gallons.
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 Health.
Signed / Date Q
Application Approved by %•�� / Date 1�0
Application Disapproved for the following reasons
Permit No. %—.2.50 Date Issued .0 -2/0,
THE COMMONWEALTH OF MASSACHUSETTS
\�/`11G�1ilDU/,� , MASSACHUSETTS
Certifirate of (foutyliaure
THIS IS TO CERTIFY, tb4t the On-site Sewage Disposal System installed (X) or repaired/ replaced ( ) on
/O " 25- _ c&- b T' _544!F.9 for
at ✓340 AAe*&-),Z!oo has been constructed in
accordance with the provisions of Title 5 and the for Dis osal System Construction Permit No. 96'-z`—C� dated
--26 9 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 9'4; Inspector