HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 28
No. 91,6-/3% SO. YARMOUTH, MA 02664 FEE'
THE COMMONWEALTH OF MASSACHUSETTS
G/1
Me MASSACHUSETTS
&kVyliration for Visposal *Votera (foustrurtion Ilerntit
Application is hereby made for a Permit to Construct ( ) or Repair (an On-site Sewage Disposal System at:
Location Address or Lot No.
3t tre-Fre-� R, 91-1
wner's Name, Address and el. No.
Jqtne)
Z-0 7- P-51
Installer's Name, Ad resAa& Bl.10
esigner's ame dddreesssand Tel. No.
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350 Main Street
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W. Yarmouth, MA 02673
S�,
Type of Building:
Dwelling No. of Bedrooms 13 Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures ,
``/
Design Flow � 50 gallons per day. Calculated daily flow 4" 7 Y gallons.
Plan Date s"a' 96 Number of sheets Revision Date l*
Title 91 r/�6ZM,an ReV_
Description of Soil /%001,417
Nature of Repairs or Alterations (Answer when applicable)
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 b thi o f Health.
Signed Date
Application Approved by -757 Date —,-)O __ 5-E
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
XaAniydt % , MASSACHUSETTS
Cterttfirate of (gontyliance
THIS I,S O CERTIFY, that the On-site .. Sewage Disposal System installed ( ) or repaired/replaced (�n
`l by A)for LSI (<lr2{P2
atr� has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 04/ted
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 4 ! 7 Inspector "�