HomeMy WebLinkAboutApp-Permit-Compliance40
YARMOUTH HEALTH DEPT.
1146 ROUTE 28
No.j- �� SO. YARMOUTH, MA 02664 FEE
THE COMMONWEALTH OF MASSACHUSETTS !J>
a� MASSACHUSETTS v "
,XXjjy trativn for (ioposal ,Sgstent Cfonstrurtion 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair (."(an On-site Sewage Disposal System at:
Location Address or Lot No.
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ST/17 .,ri�� / -7
Owner's Name, Address and Tel. No.
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Installer's Name, Address, andTel.No.
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Designer's Name, Address and Tel. No. „
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Type of Building:
Dwelling No. of Bedrooms Garbage Grinder (J b
Other Type of Building No. per Persons Showers ( Cafeteria ( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
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 ' d by this Board of Health. ^ /
Signed ` Date
Application Approved by Date <�
a:
Application Disapproved for e following reasons
Permit No. e Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
114.1,Wek /�--/ , MASSACHUSETTS
C�ertifir xte of ( vraylinurz
THIS IS TO CERTIFY, that the On-site Sewage Dis osal System installed( ) or repaired/replaced-(-� on
f—/ b LS 2& by Gfor e /y' 9✓1'%
at has een� structed in
accordance with th provisions of Title 5 and the for Disposal System Construction Permit No. ""6 dated
"I •`l.- 9 . 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'%b - Inspector
W.