HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 28
No. 9 7' /�� SO. YARMOUTH, MA 02664 FEE mrd .60
E COMMONWEALTH OF MASSACHUSETTS pt e�'00_0 Tyy,,Q�
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cNyyfi ativn for (gonstrurttun Ifermit
Application 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.
S, ��rnou 2b S3 �v-l�Jt��S Y,�vno'i n4A �2`�. 37 S
Installer's Name, Address, and T I.No. Designer's Name, Address and Tel. No. -7 .7�� 700
ox ZS82 Lo - yArmc--�A � r1lAo 2673
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinder (�
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow 3 � d gallons per day. Calculated daily flow 345—gallons.
Plan Date 517-19 -7 Number of sheets d Revision Date
Title Si;�_ (Pi RIR- 16 "jj I�iLV/)l3 • BA- tL0 � !'3 -fi%) L � ?ry-vh�9�`� �
S`e I+t�1 1
Description of Soil
_3 Z11 'ice 12 - m ed j orn Z y
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure a construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisio Ti e 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has be t ed his I _ y
Signed Date
Application Approved by Date
Application Disapproved for he following reasons
Permit No. e? �"� ��� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
YAC'n 00 MASSACHUSETTS
C9ertttteate of (gaxnyltzxnee
Flys TO CERTIFY, that the On-site Sewage Disposal System installed (�or re aired/replaced ( )on
7�'by for . �off ru �GATi� ��/� RASI e
a t"j'�1 �}y W) U J ha ben c� rutted in
accordance with the rov' io s of Title 5 and the for Disposal System Construction Permit No. % - dated
Use of this system is conditioned on compliance with the provisions set torth 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 `7 3 7 7 Inspector 6