HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
`f1146"ROUT5,28 T,
No. SO. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
, MASSACHUSETTS
FEE
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Application is hereby made for a Permit to Construct ( ) or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot No.
40t S, a7 S,914w .0 j? e- Wf3
Owner's Name, Address and Tel. No.
Gree` F►9V";1,f —Fees}
SO. Y%i gMilcith ^4. LaT,eS
«'�� .5�tlVitn .4om*14e So. YfRr aaH,
Installer's Name, Address, and Tel.No.
m t ri 4 r e�� 4-
Designer's Name, Address and Tel. No.
eon.9 l �( 7.. Ol iqd l kc
eS
/ f l*nn rs
Type of Building: 4_j
Dwelling No. of Bedrooms
Other Type of Building
Design Flow
Plan Date
Title
Other Fixtures
y%% gallons per day
Garbage Grinder ( )
No. per Persons Showers ( ) Cafeteria ( )
Calculated daily flow gallons.
S— 1 - 4 Number of sheets
V
Description of Soil 10 1'►m v 5"R'u d i i n A-- SIN'L 41
Revision Date
Nature of Repairs or Alterations (Answer when applicable) 15'00 &st l TAwk . '> - 3o y. , TW a
%Renc.ln es qS X o? x
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 (an issued by $oar of Health.
Signed Date _ 7
Application Approved by Date l®— 06
Application Disapproved for t e following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
lc�llr , MASSACHUSETTS
(E•ex#t#tra e of VComplianxe
S
THIS IS -TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/ replaced (V) on
by ",tip' -t t^a (1�_ >c, � '+<._ for te f r A I fi:J 5
at Z2 % has been co structed in
accordanwith the pr�is'ons of Title 5 and the for Disposal System Construction Permit No. `7�'6 -1.� dated
/0 — C 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 _ A"