HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 28
No. SO. YARMOUTH, MA 02664
` THE COMMONWEALTH OF MASSACHUSETTS
+ MASSACHUSETTS�) 66
FEE —To
/o --17-767i9
cNyy trafivu for Btsposal Sgst= Cfoustrurtion Ilermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot No.
Owner's Name, Address and Tel. No.
Installer's Name, Address, and Irel.No.
Designer's Name, Address and Tel. No.
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinder ( )
Other Type of Building No. per Persons Showers ( ) Cafeteria ( )
Other Fixtures
Design Flow ,33o gallons per day. Calculated daily flow gallons.
Plan Date I 0 l e._l�� Number of sheets ( Revision Date
Title
Description of Soil a4ri PIM
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 issued by this Board f Health.
Signed Date —
Application Approved by doe e Date
Application Disapproved for he following reasons
Permit No. /� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
u AAdl'
MASSACHUSETTS
Q ex#tftxttte of Gantltanve
I IS TO CERTIFY, that the On-si�o-Sewage DiWasW System installed�l) or repaired/ r placedon
by 120 ��.,, r�C. for Il��
at -r` s b e nstructed in
accordance wit thy p;gvisi ns of Title 5 and the for Disposal System Construction Permit No. dated
�T 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 12- tea '- 9f Inspector '