HomeMy WebLinkAboutApp-Permit-Compliancee'e � 0-ev-� I s T
Fzz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH S/3
TOWN OF YARMOUTH P4 %+P 28
Applira ton for Disposal Marks Tonstrur#tun 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (/an Individual Sewage. Disposal
System at:
c- ;Z?,41 � � :.... �R , .......... ... ...Z� . �� ............«....
ion re - or . • ( A
........... :....x.1.1 .t /7.��..............«... Q... ,�9.. < .. ........................ «!.✓«V�/
`� Ow 6!3e✓S T a J _A1 Address ___/L
R
Installer ��� p S Address
Type of Building `1 /v Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms--------------- ---------------------------Expansion Attic ( ) Garbage.. Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ...-•-•---•-•--•...................................•-.............---.--..-------•---------•--......-.....-....-•-----....................--•---------
Design Flow............................................gallons per person per day. Total daily flow ............................................
Septic Tank — Liquid' ca.pacity............gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .................................................
.--•---•---•............. Date ........................................
Test Pit No. 1................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 ..................................................................................
................................................. .......................... ......1.. S......-. \.....................-------•-•--•------•--•-------....----••••----...---...-----........
Nature of Repairs or AlteradQw — Answer when applicable..........
.....
Agreement: 'j
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 by the board of health. g
Signed_ I`7..../._�--
, XDt
ApplicationApproved By ............. . ..•.................. .---•------............................. .......... .. ......
Date
Application Disapproved for the following reasons: .... ..................................................................................0...............«....
... ..... .............. ... ' - - / Z •...._... O ...... •-......
Date
PermitNo.. - -•........... ............. Issued.... v .... .........--------•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrttf iratp of Tomplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by. ...... !s ...... j'�-r�S Cys.«.�--�.:.....
Installer
at..... ._...:_VD/ <u....�u✓.... S.� L. If . /Lh r''v �.----- ................................................................
has been installed in accordance with the provisions of TIT T e State Sanitary Code a de• in the
application for Disposal Works Construction Permit No......�31.0�f� .... d.....-..91 ............
THE ISSUAN E 9F THIS CERTIFICATE. SHALL NOT BE NSTRUE AS UA ANT E THAT THE
SYSTEM WILL Ci SATISFACTORY.
DATE....................., y....1 ....................................... InspectOr. ................ : �� �.. ....................