HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 26
No. S' SO. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
Try'1(1"OU , MASSACHUSETTS
FEE SO CI
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Ammlication is hereby made for a Permit to Construct ( ) or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot No.
Owner's Name, Address and Tel. No. 8Z2�
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S. YArY-1,6UiN MA
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s. �j RU4-),, I, 62.664
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel No.
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ice• Izmo� � oz�7
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinder (ilk
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow 33c) gallons per day. Calculated daily flow gallons.
Plan Date 12, lq& Number of sheets Revision Date
Title SiTF P(ftiq CIn,%-&C R Ujhaf 99i 6, S 04-v+i~-
Description of Soil
J
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Agreement: !
The undersigned agrees to ensure the construction and maintenance of the afored4ribed 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 sued by this B r of th.
Signed Date
Application Approved by Date _ S�
Application Disapproved for t following reasons
Permit No. 9e Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
V At -Y►, 0 tM4 , MASSACHUSETTS
Cel rtifirate of Complianre
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ( ) or re aired/replaced (Kon
by for ChA„Ln-� Wh.
4
at Jw 3-+'�--rj n &j AUl:. A- Irn m LPH has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.—7/a dated
Use of phis 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 designed. This
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DATE !Ta,— �� <' Inspector / .�,.
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