HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrur#ion lirrmit
Application is hereby made for a Permit to Construct
System at:
...................AV..-Q ......................
.
11 Location - Address
................ .
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Owner
.............. :X12114�...........................
Installe
Type of Building
Dwelling — No
Other — Type
) or Repair (v --)"an Individual Sewage Disposal
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....................................
Ads
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�......�...:.......1i3.....-•••--......
Address
Size Lot ............................ Sq. feet
of Bedrooms....................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures..........................•----------------............----.....--•---..............------.......---.....---......----.........------------...........
Design Flow ......... , ......................gallons per person per day. Total daily flow ......... -aZD-------------------- gallons.
Septic Tank L Liquid capacity. 40M.p1lons Length ..... 7...._. Width....5 . Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No...../ ............. Diameter..... A'f...... Depth below inlet ... &�......... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Descriptionof Soil ....................................................................................
Nature of Repairs or Alterations — Answer when applicable.... =.� , �_._..1. ?C2p.: e 7 •tom- C l ? --.
..............vm--1 � ..... iD..�i.1=i......t !� C? ......................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued y the board of h Ith.
igned. ... ..��i---•��rdZ
Application Approved B /'� =D Z
Date
Application Disapproved for the o wing reasons .......... -•----•.............•--------••-••--.........--•---•----•-•----------........._...................._
....................•-----..........-•---.....................................---••-----------•------------- •---•--•----......-•-------•..._.......-----•••......._..........-----••-•--•-------••-.-----
.2- - ^� Q Date
Permit No.... .. ....................• Issued...... L_ I ........------.....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irrtifutt#r of TOMpltttnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( L),-""
bY-.................................... .1).t s.....----...........................................-•-•-.............---........................
..Installer
at----------------•-••----........� .....1'z!f�` .l!!!i !! /i /�`' ' ... - .P_.: �...,c.s!1'L�: .....-...........................
has been installed in accordance with the provisions of TIT�5 of The State Sanitary Cgde as escri e n the
.application for Disposal Works Construction Permit No............ ^.� ... dated......-..1.......�......
THE ISSUA CE OF THIS CERTIFICATE. SHALL NOT BE STR E S A GUARANTEE T AT THE
SYSTEM WIL NC ION SATISFACTORY.
DATE...........`..........�"................................... Inspector::............ .. ?..... ..........................