HomeMy WebLinkAboutApp-Permit-ComplianceNo.�n ................ Fps ..1.. ..._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appiiratinn for Disposal Works Tontrur#ion Errant
Application is hereby made for a Permit to Construct ( ) or Repair (p<) an Individual Sewage Disposal
System at:
---....%......... .... 5.•.A..d.d..r.e.s.s � orjIyot o.
........�..=........-----••------•--- aVI!: ............. ..._.....
Owner ddress
a U G7 t„+v In C:4N7
Z —7!n/t -f _C AJ ..
Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling — No. of Bedrooms.............................._.....__...Expansion Attic ( ) Garbage Grinder /1.1ri
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures
W ..
Design Flow ---------------- ---
---•-----•----gallons per person per day. Total daily flow ............. 3.................. gallons.
G4 Septic Tank — Liquid capacity/.40.9..gallons Length ................ Width ................ Diameter_- ................ Depth ................
W Disposal Trench — No. 1...... Width ........ Total Length ..... ss.71...... Total leaching area ...................sq. ft.
3 Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
,aa 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 ........................
a
............. •••••-•••-•.............--- •-............ •--•-•••••....
_-••- ...........
_.... ••-...
_-... ............. -..... -__-_-_-------
_........ _..............
0 Description of Soil .....-•---•-----•--•-••........................•---................----•---.......---------------......._.........._.............-•-•--•---••--.............--•._.......
W
U-•-•..............................................•------•---•-•-----...............
•--•..........
..................
-...............
_.-•.............
.................
•- .........
....._
UNature of Repairs or Alterations - Answer when applicable____el ...... aq .-
d_ ...-.... ..si.....e_
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 ri/ie by the f health. �J
Signe------ -- --•---•- -------- - -...................... �! ...�.
• a
ApplicationApproved BY -•--- ---------------••-•- ...._......_ . .............. •--••---•--_.. .... ' ...... ... .........
Date
Application Disapproved for the following reasons: .................
......... .......
..................................
......
..----•--••---•---•............................................... ..........................................................................
..
......
..............
2- - �. , Date
Permit No...S. .�................... • -..... Issued....... `3` �. ...................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifiratr of faoutpiitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed,( ) or Repairedby
........................................................nL
..........................-•-- --• .............................----
Installer `
at.............................................................. ...................................... '=............
S'C.h...... th.L ...................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod as &s ribed in the
application for Disposal Works Construction Permit No �_ .._....`.._ �.._-:..._..._... dated.__. -a-._ _ �-.a�c�,�� ...._......
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................:.�_Sz ............................. Inspector_ . . ---- . ...: �..�..� �i