HomeMy WebLinkAboutApp-Permit-ComplianceNo...r. 3�S_ Flms.....�.. ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal Marks Toustrurtiun jkruat
Application is hereby made for a Permit to Construct ( ) or Repair (\/�_an Individual Sewage Disposal
System at:
................. �. )!.I . .......�2-�.0 p......V---------------- �''2-�f---
�% Location - A dress or Lot No. (�
................ "__� i1JL: r ... (7 r_ .✓._v!!4Av = 1 .............................
Owner ddress
Installer Address
Type of Building Size Lot ............................ Sq. feet
V Dwelling — No. of Bedrooms.__.-. ................................ Expansion Attic ( ) Garbage Grinder V\�e
Other — T e of Building ...... No. of persons ............................ Showers — Cafeteria
P4 Other fixtures -•-----•-------•--•---•--------- •. -
W Design Flow.....--... ...................gallons per person per day. Total daily flow ....... ,.. 0....................gallons.
WSeptic Tank 4 Liquid capacity. -"gallons Length-__- ...__. Width.. ........ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
��Seepage Pit No.------ . Diameter...... °
........_.. ��_.__._ Depth below Inlet_.__......_._._ Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
aTest 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 -------------------------------------------------------------------------------------------------------------------
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Natur.Repairs or Alterations—Answer when applicable.-1!�?.`�f-`.._.\004_!-`�rP................
(� f� �.. � r -:...I -----------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi� 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' ued by�heof health.
Sign ......... • .....1,__ b�yhof
.............................. •�_� 2 f�' `��'
--------•------• to -`C
ApplicationApproved By. .� -- .................... ......---•---------•-•--------...---•- ------ 3 --'--------------j ---
Date
Application Disapproved for the following reasons:..... -
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- Date
PermitNo ..... .............. ---------------._.._.----- Issued .................`u ..........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
All Qrrtgflratr at Wuntpitaurr
THIS IS TO C;
CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by.................................................... ��...!A.l �� ...._1.. ! i r-"-------------------•----------•--...........................................-•-----•---
Installer
at................... ............................ J.�:.L----- �•s-eb_U_�C-s. a" 5� - v £—........... C�--1 = -- 5.14 _.ru.r _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 ................... dated ... .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANT7 THAT THE..,
SYSTEM WILL FUNCTION_ SATISFACTORY.
r
DATE..............................._�.... :� ..----.-------.:.---•- .... Inspector ----- /v -- -----------------•---