HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 F(()UTE 28
No.
SO YARMOUTH, MA 02664 FEE -S
THE COMMONWEALTH OF MASSACHUSETTS (�i7
AAmr?� MASSACHUSETTS /C,
cNyy rativn for Pioposal �Vstem (gonstrurtion Fierntit
Application is hereby made for a Permit to Construct ( ) or Repair (V/an On-site Sewage Disposal System at:
Location Address or Lot No. y 11917 5ff M ,-
W
tr"s Name, Address Tel. No. t
N
VVQeA
In is N e Addre n Te .No. ??
s�alle S < C Cro
D7 er's Nam , Address and T 1. No.
�, a
Type of Building: �'�✓�'
Dwelling No. of Bedrooms _ Garbage Grinder ('A�rb
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow
Plan Date
Title
Description of Soil
gallons per day.
_ Number of sheet:
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Calculated daily flow
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 provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has bee ' by hi oa o h.
Signed Date
Application Approved by �kkgzv Date 4p
Application Disapproved fort a following reasons
Permit No. 7l eld 3 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
[SjZ , MASSACHUSETTS
Terttttrate of (gomplia ttrz
THIS IS TOCERTIFY, /that the On-site Sewage Disposal System installed( ) or repaired/ replace ) on
S 16 —"'-1,6 by G LG- 5 _ for—���i�—��/���/c�
at /'7
has been co tructed in
accordance with therovisions of Title 5 and the for Disposal System Construction Permit No.dated
9-211' ' . 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 -S /� �� Inspector