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No.
YARMOUTH HE LTH DEPT.
1146 ROUTE 28
SO. YARMOUTH, MA 02664 FEE _�/
STH, E/E COMMONWEALTH OF MASSACHUSETTS
T -"-f . MASSACHUSETTS
Applirattun for Roposal '$ptem(Eanstrurtion 11erutit
Application is hereby made for a Permit to Construct ( ) or Repair r/an On-site Sewage Disposal System at:
Location Address or Lot No.,0/O& e— ® 7^
Owners Nme, Address and Tel. No.
7l%�.1f-s Oc-
11/
Installer's Name, Address, and Tel.No.
Designerame, Address and Tel. No.
59C,3
3g8 -352,-L
Type of Building:
Dwelling
Other
Design Flow
No. of Bedrooms
Type of Building
Other Fixtures
0
Plan Date ✓ (�- C_')e
Title — P J
/ Garbage Grinder ('QC)
No. per Persons Showers ( ) Cafeteria ( )
gallons per day. Calculated daily flow -� gallons.
Number of sheets Revision Date
rr1 Irl e Lf'G!/ // ✓ �f'�iG '�Gld .+s ?S V'
Description of Soil CSe_"';rel—
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 Envirom e t Code and not to place the system in operation until a
Certificate of Compliance has b s ed by is Boord of Hea 1 .
Signe !'� (/ Date _
Application Approved by Date f 9,4
Application Disapproved for the'following reasons
Permit No. F< --252— Date Issued 'F—,(-�-- q,,6
THE COMMONWEALTH OF MASSACHUSETTS
yZ a3®/;/7 MASSACHUSETTS
Certifirate of (gumplianrie
PIIS IS TO CERTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/replaced (on
`e° 7C - by 1��/// for �/���37✓ 5 tJL
at .< / Z77has been constructed in
accordant with the prov}}cions of Title 5 and the for Disposal System Construction Permit No. �� `� —dated
- /-7 pfc . 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
Certificate expires on
DATE > —e'? & ' � Inspector
guarantee that the system will function as designed. This