HomeMy WebLinkAboutApp-Permit-ComplianceNo.../....... Fzs....,� ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �l
TOWN OF YARMOUTH
Applirtt#inn for 11ispnsttl Works Tonstrur#ion jkrmft
Application is hereby made for a Permit to Construct
System at: .......
�
,/ ............................
Location - Address
- ...................................................
Owner
---------------------------- --- ----
-------------------------•--------------
Installer
Type of Building
Dwelling —No. o
Other _'r e of
) or Repair (1,,<an Individual Sewage Disposal
-----------------------
or Lot No.
...........................................
----------------- •-- rens........- >---------- .......e--_..
Ad ress
�...�.�AA
...a...Y...._..
Address
Size Lot ............................Sq. feet
f Bedrooms............3...........................Expansion Attic ( ) Garbage Grinder ( )
yp Building No. of persons----------------------------
Otherfixtures-------------------------------------------------------------------------------------------
Showers ( ) — Cafeteria ( )
Design Flow .............. ,1.1..fl..................... gallons per person per day. Total daily flow ................ .3.� Q ................ gallons.
Septic Tank — Liquid' capacity./..Q.QP.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. 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 — Answerwhen applicable...__..W.C._U._ j4
�uac 1 Qa o --7. ......... c.�..44..----- 2.'.. �sTcts � .._Wakw-------------------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 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 ealth.
Application Approved By----- _._/__ ........
Application Disapproved for the following reasons:
Permit No.....&--- ��-----------••--------------
..---_.,ll.-_� ..g._..._....
....I-1 --i -t?.r........
......................•-----------......p............•----.....---•----.--•--
Issued........./... Q..__/ ............Date......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(9rr#ifirtt#r of Tomplitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
a; _f .1
by
) or Repaired (k4'
has been installed in accordance with the provisions of TIT A 5 of a State Sanitary Code s fes d in the
application for Disposal Works Construction Permit No.__._.�?:..`"'���---•---.--.
date( ...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA EE THAT THE
SYSTEM . WILL FUN TION SATISFACTORY.
DATE...----..11=-�•�� _`
........................................... Inspector .------. ........