HomeMy WebLinkAboutApp-Permit-ComplianceRMOUTH HEALTH DEPT.
C: /5e5�P/%146 ROUTE 2
No.� .YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
FEE W
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P,�4 -it 11
(�,Vy rativn for jBielaosal *Votent Cgonstrurtion jJerntit
Application is hereby made for a Permit to Construct) or Repair ( ) an On-site Sewage Disposal System at:
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Location Addres, or Lot No.
O ��, Addressed Te No.
Aller' am Address, d Tai
Designer's Name, Address and Tel o.
K4.
Jc, i4v IVo s
�o.-, .
2 z- as
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Design Flow
Plan Date
Title
Other Fixtures
3'!=> gallons per day. Calculated daily flow 33c-> gallons.
�b'T . 1 t a � � 1 �- Number of sheets Revision Date
1 I
Description of Soil !Q—.Ae— je �^
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to
system in accordance with the pr9wrl
Certificate of Compliance has A0
Signed _
: Application Approved by
the construction and maintenance of the aforedescribed on-site sewage disposal
,Title 5 of the Environmental Code and not to place the system in operation until a
b�d of Health. /
Date�Aq e,
Date 7„/��/ 9�s
'"' Application Disapproved fof the following reasons
Permit No. Date Issued 2_4 �
��� • ��6iti'S 'fir
THE COMMONWEALTH OF MASSACHUSETTS SUP L. WAW
MASSACHUSETTS
, 3v/c7
Cer#tfirate of (gontylizzure
THIS IS T� CERTIFY, that the On -s to Sewage Disposal System installed or repair d/replaced ( ) on
C `^'t` by _t ? GA (d S ��e' for ��b P�.d �Al���� �
at SP has -been-constructed in
accordance with the prov'sions of Title 5 and the for Disposal System Construction Permit No. dated
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 ��� �� y Inspector