HomeMy WebLinkAboutApp-Permit-ComplianceNO
NO -1111 00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrudion rrrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
& ..... � �Aq. 1E .. .... P'4f.'y .........�?,VZ-AJA&w?d ........::.....L:. . -3 .........................
LocattolL - Addres% or Lot No.
JAA.J&AA,& ...... . fi ..... AIWZ�Uiai .......................................................................... --- * . ................ * ........
.&;tg ............................ owner Address
................................................... ..... ............ W.::"11y1111_11
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 ................................ 0 ......................................................................:-----•---------------....................----
Design Flow .................. J1 A .................. gallons per person per day. Total daily flow........... 3J j P ...................... gallons.
Septic Tank — Liquid'capacity.10PA.gaflons 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 ..........................................................................................
.........................................................................................................................................................................................................
................................................................................................................................. 0 ..................................... . ...........................
Nature of Repairs or Alterations — Answer when applicabl$ ..... ... ...
........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 lie4th-
Signed....
Application Approved By,
_A—De
.....7 . ........
�ate
Application Disapproved for thf followingf"ons:_1 .......................................................................................................... -
............................................................................................................................................................ ............. .............................
5 Date
Permit No.... .................. Issued.......... q . ............. Z., .......
IiDate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
&rfif iratr of T-nawliana
THIS IS TO CERTIFY, That thq Individual S,ew,-Lge Disposal System constructed
by.
) or Repaired ( 1,4
at............................................P -4-i-11 ------- WELI-r ..... .........................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a describ4d in the
application for Disposal Works Construction Permit No.__... 9 .Q , .3r..Q.... dated ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARI-17TEE ThAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...........
.................. Inspector... ..
........