HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
No.
96- 9 1146 ROUTE 28
SO. YARMOUTH, MA 02664 FEE
THE COMMONWEALTH OF MASSACHUSETTS j to
7721 MASSACHUSETTS 1
c yjjltirafivn for PisposalSVeitem C notrurtion 11orrait
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an On-site Sewage Disposal System at:
Location Address Lot Lot No.
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Owner's Name ddre�s.aad Tel. No.
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Installer' Name, Add s, an Te1.No.
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Desig�e`e, Address and Tel. No.�
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Type of Building:
Dwelling No. of Bedrooms Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Agreement: l
The undersigned agrees to ensure the construction and maintenance of the aforedesdiibed 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 ha Zbythis Bard Health. g
Signed I" Date
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Application Approved by Date �r /
Application Disapproved for the flowing reasons
Permit No. / Date Issued
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THE CQMMONWEALTH OF MASSACHUSETTS
7251 MASSACHUSETTS
&rttftrak Of (9jaMpliMtre
THIS IS CERTIFY, that the On-site Sewage Disposal System installed( ) or repaireed replaced on
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—by U�i�L!/�� SL'T/G for
at / � hasbeen constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ill - % 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 a3 - g Inspector �/