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YARMOUTH HEALTH DEPT.
1146 ROUTE 28
No. % / 6 SO. YARMOUTH, MA 02664 FEE 04
/�,,/1THE COMMONWEALTH OF MASSACHUSETTS parmdto-k , MASSACHUSETTS�eo,00;3G7,�,
cXjjylirafivn for Pispasal Sgstent C oneitrurttun 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an On-site Sewage Disposal System at:
Location Addresso Lot No.
0) (0 Ini N flea m Or- -i�9'/ 9�
ner's Name, Ad ress and Tel. No.
/t%2 /,%!` f Aa,l'eO
Sou ctr WO
-.011 .e -
Installer's Name, Addre,Ss, IddeldNCO
Designer's Name, 'Add and el. No.
/9t�yf ,(,e�/! 7 �ervices.
350 Main Street
3 l� ma -,,r !M " d ld
W. Yarmouth MA 0267,3
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Design Flow
Plan Date
Title
Garbage Grinder ( )
No. per Persons Showers ( ) Cafeteria ( )
.30 gallons per day. Calculated daily flow 330 gallons.
+ 9 - QE> Number of sheets Revision Date /A
Description of Soil /1C /` IF 11 4�0
Nature of Repairs or Alterations (Answer when applicable) .p.r� IA -A)
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 Bo d of th. Q
Signed Date S^ m
Application Approved by Date
A
Application Disapproved for the following reasons
Permit No. �� —�3 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
A.rM o U 4- 1A , MASSACHUSETTS
Certttt.cate of (fumyltnure
THIS IS TQ CERTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/replaced (V) on
r-A&)CD for /�l4 �i,4r�c� ,fe/v,�CeS
at d (o S• 1PA14. has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 96 - /3 04 ted
-5- `",d ?6 . 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 c�
DATE 3 y / Inspector