HomeMy WebLinkAboutApp-Permit-CompliancerV—/ivY
YARMQUTK HEALTH DEPT.
46 R6UTE 28
A No. 96
O. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
,MASSACHUSETTS
FEE �Sv_ 60
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Application is hereby made for a Permit to Construct ( ) or Repair ()6 an On-site Sewage Disposal System at: Slwq
Location Address or Lot No. Com„ 7,,Q1e(/' xhr5l Owner's Name, Address and Tel. NoIR
Type of Building:
Dwelling
Other
Design Flow
Plan Date
Title
No. of Bedrooms
Type of Building
Other Fixtures
tlip allons er day
Garbage Grinder (� U
No. per Persons Showers ( ) Cafeteria ( )
Calculated daily flow
Number of sheets
Description of Soil
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
ill
d gallons.
Revision Date
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 issue by this Boar of Health.
Signed Date
a - 9
Application Approved by Date 67
Application Disapproved fo{the following reasons
Permit No. 1K —.2-3l Date Issued g ,O)o ^ �F6
THIS IS
P - /, -
t
TH�COMMONWEALTH OF MASSACHUSETTS
/iAFX rn� MASSACHUSETTS
Tex-#t#trx#e of Cuxztltarcce -,,�
CERTIFY, that the On-site Sewage Disposal System installed ) or repaired/replaced ( ) on
-by /y% for f6lk < '
has been constructed in
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
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
C Aires on
DATE 4n � t� Inspector
.
Installer's Name, Address, and Tel.No.
Des''g Name, Address and Tel No.
Type of Building:
Dwelling
Other
Design Flow
Plan Date
Title
No. of Bedrooms
Type of Building
Other Fixtures
tlip allons er day
Garbage Grinder (� U
No. per Persons Showers ( ) Cafeteria ( )
Calculated daily flow
Number of sheets
Description of Soil
Nature of Repairs or Alterations (Answer when applicable)
Date last inspected:
ill
d gallons.
Revision Date
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 issue by this Boar of Health.
Signed Date
a - 9
Application Approved by Date 67
Application Disapproved fo{the following reasons
Permit No. 1K —.2-3l Date Issued g ,O)o ^ �F6
THIS IS
P - /, -
t
TH�COMMONWEALTH OF MASSACHUSETTS
/iAFX rn� MASSACHUSETTS
Tex-#t#trx#e of Cuxztltarcce -,,�
CERTIFY, that the On-site Sewage Disposal System installed ) or repaired/replaced ( ) on
-by /y% for f6lk < '
has been constructed in
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
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
C Aires on
DATE 4n � t� Inspector