HomeMy WebLinkAboutApp-Permit-ComplianceNo.__:...1.._l!_....... Flcs.........---/.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for flispoottl Works Tons rurtiou ' ramie
Application is hereby made for a Permit to Construcl
System at:
Lo tion --Address ••�-•
..............�A v L :_------.....4.!_ !=_ . ei[------____-_----------_•____________
Owner
Lw/IEit/C_� �oNo ✓..
Installer
Type of Building
) or Repair ( ) an Individual Sewage Disposal
........................................
or Lot No.
•..................•----_._........-•-••-•----•--____._......._........._........-....._»....__
p'/�1d/ylress (�rj
/!T !_ .f/A�i�%l.f..._.I. Cl.
Address
Size Lot /2 a..__.Sq. feet
Dwelling — No. of Bedrooms .._.......------------------------------ Expansion Attic (//a) Garbage Grinder W6)
Other — Type of Building ____________________________ No. of persons ......................... ___ Showers ( ) — Cafeteria ( )
Otherfixtures•---...•----------------•--._.........-------------......_......-------------•-•--••----------•-•--•-••••-••----••-••••--•-•--___-•-____________....__
Design Flow ................ &9 .................... gallons per person per day. Total daily flow ___...........3._•�................. gAlons.
Septic Tank —Liquid* capacity/0A4C%__gaRonsLength................ 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 ........................
Description of Soil---------------•___------------_____-----------___------------
-------------------------------------------------------------------------••-•............._.. •----• -- �••-----------•-•-
q:u
��l `�tc��' tiS�f �ow-`��jL- -_ __.
....---.......-•----------• --
Nature of Repairs or Alterations — Answer when applicable ...... AZO " .........................................
. i
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--- ...---�....._�-----• v .......
Agreement: D -M c_
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TAI TLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been •ssued by the boaAd of health.
3I
Signed'` yy.
Application Approved By ___ _ _______...... .... :....._........_...____________, G` _ G_.�Z,....
Date
Application Disapproved for the f ollo a g reaso :---•------------------------•--...------------•----•----•------..._..---------•-------...-••---••------•--......
....................•.----•------•---•------------•-•---•---._....._-•--•- -• -•-••-----...••-.--•--••--•---------....-------•-------•.......-�---.... �..-------••----••-------•---•---
Permit No........... ..'.l..�A.. ........ Issued_...._-1�--.._....�.�.........
Date .. a _
m_
------------
THE COMMONWEALT,H.OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irriifirttfr of Tomplitturr
THIS IS TO CERTh�Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (�--
by........... e,� `- • 1,10 N o.>..'.'".J..........:....•------•---------:..--------••--•-------••-•--------•----•-•-----.............----------.........---..........._
's- Installer
at• ----...._1r'--. P.��....�.....1........ ..... �=-------•-••----...--------...--------._....------....----------•-----._._......------------------•-•--•-----...._
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..,�.�:..-a. 1.__r! .................. dated__- _-3.-_9y
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE
SYSTEM WIL FU CTION SATISFACTORY.
DATE ......... �
• - --•---�........... ......... ......... ........•---• Inspector -._...._..- -------• -............................. ..W._.._..W �„