HomeMy WebLinkAboutApp-Permit-ComplianceNo...L. a(-9 FzZ ............. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonuuniion 3prruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: 9 )5
.�
..... wu -- ....... ............................ ......................... T . .......f'.Y. d ' :: 51-----------
�� �-.._-. Lo�jtion Ad ress , I �. or Lot No.
.................M_tC_ .Y. �� .5" �.L%�:�.•._.._._._._._._._..---.._._._..._........_.__._....._J.�.�--�.�r2�---G�..r%:�.1......•......................
caner 12d"
ess
V
W AC=S �+iJ ......
.... ... ...._...__••---------------•.....•.............--.................••...�' Installer es
Type of Building Size Lot ............................ Sq. feet
V
Dwelling No. of Bedrooms ..... -. ---------------------------------- Expansion Attic Garbage Grinder
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures ----------------------•••-•.--•- ... _
W Design Flow.......SSZ57....................gallons per personer day. Total dail flow ...... ��.�?........................ gallons.
WSeptic Tank I Liquid capacity. -`gallons Length ... V..... Width...... Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .........._..__..... Total leaching area .................... sq. ft.
Seepage Pit No ....... /............ Diameter ...... la....... Depth below inlet .._..SC.......... Total leaching area..................sq. ft.
Z;. Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. 1 ................ minutes per inch Depth of Test Pit .................... Depth to ground water .............. 0.........
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
x•.......................
0 Description of Soil .........................
W ----- --------------
---------------------------
-----------------
•--------------------
---------------••------........----------------------------
-------------------------------------------
.- ----
x-----...-••--•-•••------•--------------•-•--•-----------------••--••--••-•---•--------......_..••••----•.............•---••......•••• •.............................................................
U Nature of RePairs or Alterations — Answer w n applicable.. -,;..4 :[ �..-..(_QO_Q... T!. L -'-fa :!:LX-._._•-.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE, 5 of the State Sanitary Co The undersig further agrees not to place the system in
operation until a Certificate of Compliance has bee >s ed b -It of health.
Siga ...... ....•.. ---•--------------------•-----..----..._..............................
Da
Application Approved By. ... --•-----•....................................................... ----- -- I !Q `�.----
Date
Application Disapproved for the following reasons: ..............................................................................................................
---------------------------••---•••-•---•••---------....••--•.....•-•-......-----•-•-----••--...••-•-•--•.._...-------------••••-••--••• •-•------••--•-••-••---•-• •--•••------..... ......................
6 IR
Permit No.-- --- ----•- • -----•......_ Issued.......
- ...---•------•----------• ... Date ...--
Date
---------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifirtt#r of Toutplianrie
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�4
by..................................... ................................ ................................................................. __...... _
Installer
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.. `j:_:::_ .---._..._.:
' ._ dated---. _ ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�
Inspector ...... ....... %...... j'. /4"-
... ;..
f