HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT,
1146 ROUTE 26
No. SO. YARMOUTH, MA 02664 FEE
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS PJ6(� /
�yjjfirativn for Bisposal *Votem (fanotrurtion jJermit
Application is hereby made for a Permit to Construct ( ) or Repair (I �n On-site Sewage Disposal System at:
Location Address or Lot No. 5-7Owner's
4 �_ L9//. f';�& I v 1-04
Name, Address and Tel. No.
h u,
S. �& rk)-, - ,,. Zig
Installer's NKhe, Address, and Tel.No.
Designer's Name, Address and Tel. No.
�3 ,S i J -r 11-0
Type of Building: n
Dwelling No. of Bedrooms J
Other Type of Building
Design Flow
Plan Date
Title
v
Other Fixtures
3 3 d gallons per day.
Garbage Grinder ( )
No. per Persons Showers ( ) Cafeteria ( )
Calculated daily flow
Number of sheets
Description of Soil �� S� t L� r
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 provision f Title 5 of the Environmental Code and not to place the system in operation until a
;'Certificate of Compliance has been ' e y is B o e
Signed ��i- Date s" ��'
j'Application Approved by Date / �o
Application Disapproved for the following reasons
Permit No. C7,y —/ 5�; Date Issued -5�7 _� `qf
THE COMMONWEALTH OF MASSACHUSETTS
�-%g / Y►� X41 MASSACHUSETTS
C9.ertif rate of (fompltaare
THIS IS TO CERTIFY, that th On-site Sewage Disposal System installed.(_ ) or repaired/replac d (i) on
b IF- S r J4,rS c- S'l - for �� h n 5'1�i'h -at
at 1�1 t j-9/1 T° IP i y A 14 F `" has been constructed in
cle
accordance with the rovtsiSns of Title 5 and the for Disposal System Construction Permit No. 9� "��4 dated
11'-2 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 Z�j2F, �,
DATE -s Inspectork
THE COMMONWEALTH OF MASSACHUSETTS
No. Ur, f cn:c 0 , MASSACHUSETTS FEE
�ts a$�xl S#eztt C11unstrurtijan Permit
Permission is hereby granted to 5 t 4 io ') lY6.S CGhS2-
to construct ( l o repair Vi an On-site Sewage System located at $' le
7°
�(MC -I J`
and as described irk the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed withinthreeyears of the date below.
DATE (a Approved by
FORM 1255 Rev. 3/95 A.M. SULKIN GO. - BOSTON, MA - -