HomeMy WebLinkAboutApp-Permit-Compliance��16
t
a
U
a
a
a
W�
W
Z
G4
W
U
11
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fzs.......�.
iptira#ion for Disposal 19orks Tanstrudion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair (N an Individual Sewage Disposal
System at:
......Wr...`�I'!'�i.?•�'t ..................... OT...:T .� v M. ?. '. !.. .............
Location Address or Lot No.
..9..4
................................... ---•----•--s !9 ►�.�,�.......................................................... ..........
Owner Address
G.... E c... =• .. ............... .
................... er_ :'.....
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .......... 3 .............................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.........................................................:......•-----------•-•--•-••----.........-----•----•---............................-•-•.._...
Design Flow ........... 45757 .......................gallons per person per day. Total daily flow ....... ---- 3.-I=;t-------------------- gallons.
Septic Tank — Liquid ca.pacity.1 02legallons Length..! Width.....? ...... Diameter ................ Depth....,/.2 ......
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ........ %........... Diameter..... h�....... Depth below inlet----- ...... Total leaching area .. �. sel-�frGPD
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............................................•--•-------•---.............---.........------•---.....-----....-----•----•--•--•-•--.....------....--•---••-•••-•-•--..._..
.......................•--•-----•---------•----•---.....---...--------............------.............---•-••-----•----•-----.....................................--•----•--...._................._..•--•
..........................................................._..--•-••--------------------..........--------------------•...----..........--•--......•-•-•--•---•-- ..........•. .
Na epairs or Alteratio s — An r hen a plicable___.1�._.. S-._ r�4:!` � � � � 1�!
b ...........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal min 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 by the board of health.
Signed. -- .... //t: e J1.�G....... .............• 9. L z.......
ate
ApplicationApproved BY •-- .. •-- ........... •........ ........................................................... ----- --------
Date
Application Disapproved for the follow' g re ons:................................................................................................................
.......................................................• -• •....-... ...............................T......................................... Date
Permit No. .. .. .......................
Daft
THE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(arriiftratr of Tout pitanrr toy'
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X)
by.... --.^�.1-2se_ E ic5-k G .
taperIns
at•-- 3 z......� {/.D�..-.c�...� 1.�/ -t..1.t...Y..-►�z.r.1'i� .... .........
has been installed in accordance with the provisions o TIT 5 of The State Sanitary CAe s c ibed in the
application for Disposal Works Construction Permit No.......L ..�.���.... dated ........... ..1_.. _ _ ..._......
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRU D S A GU A E THAT THE
SYSTEM WILL UN ON SATISFACTORY.
DATE..........I............��.......................•---............... Inspector. ...--•----•-- ---• � = ...... ._ ... ...... ....:.