HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT. �J%7
No. SO Y RMOUTH, MA 026M FEE �� v
THE COMMONWEALTH OF MASSACHUSETTS "
��(1.1V10& R , MASSACHUSETTS
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(�vyylirativn for Pispoe-al Sgstem Qlanotrurtion 11jermit
Application is hereby made for a Permit to Construct ( ) or Repair (A an On -site Sewage Disposal System at:
Location Address or Lot No. —. L'
Owner's Name, Address and Tel. No.
15 NANTuGk'b" r M9 il✓! � Gd
WI LLIoM Tf,l r-onO
S. 'lAayr-O UT14
IS NAN10CV b-C rLV
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
box 463
w.OF—PA15 3 g—Z7tb
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow 33D gallons per day. Calculated daily flow 3 `f Z gallons.
Plan Date 7 "g' 1 6 Number of sheets 6NE Revision Date
Title 51TF_ ANO S6w,oGG r V N
Description of Soil 6'
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 issueq Vy t ' Bo of Health.
Signed Date —
Application Approved by Date
Application Disapproved for the following reasons
Permit No. � _ Date Issued 7 _. ZZ
THE COMMONWEALTH OF MASSACHUSETTS
L/.rfiLL�s01�7t/ , MASSACHUSETTS
C9ertifirate of OLTozl<tylinure
THIS IS O CERTIFY, that the On -site Sewage Disposal System installed ( ) or repaired/replaced ()C) on
/" by r1olye-6- for lk/ 1-1 G 4d lozl ZZEKFDz!tI�>
at �S �✓����/«� > ' '.-b has been constructed in
+ accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _-�l1dated
Use of this system is conditioned on compliance with the provisions set forth below:
`w The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
J
Certificate expires on
DATE: o 4 Inspector