HomeMy WebLinkAboutApp-Permit-Compliance_Ot- - 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
AppWa#ion for Disposal Works Tonstrudiun jrrmit
Application is hereby made for a Permit to Construcl
System at:
............�__....l121.�1...?.:......`.Poe:T...........
-Location - Address
--------------------------
Installer
) or Repair ()<) an Individual Sewage Disposal
...... aT-S3............?AP = i d--------------------------
or Lot No.
................................................................•--......----••--•--..........-•--
.-- Address
!r�o
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.................4-.------_----•----.Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons _------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures.....-•-•-•-------------------------------------------.-----•------•--•---------------••--............-•--•---••-•------.....--•-•--•-•---•-----------
Design Flow ................... �.1`�------------------ gallons per person per day. Total daily flow .......... 1-1..a ................... gallons.
Septic Tank— Liquld ' capacity/!iI O_gallons Length.. -Z.(2 ....... Width.. - Diameter ................ Depth ..-..........
Disposal Trench — No ..................... Width.................. Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ....... I.......... Diameter .... Z ...... Depth below inlet ----- 6.!....... Total leaching
Other Distribution box (K) Dosing tank ( )
Percolation Test Results Performed by ,16.4.-.... ...................... Date ....9.:-.2._6 ....... YA........
Test Pit No. 1................minutes per inch Depth of Test Pit .... I. .-._----- Depth to ground water..A24 !6rL6...
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-:
-----—�;`----•--------------•----- -•.
-- c--•--- —----•
--------_ L-13
r ---------........_ ........ .E.. ,�
Description of Soil ........... 3 .ftA1..-- --- ,VV.6---------- ---------------" ..-
1 N.Q)
..-•-•-----••--••-••••-•••-•-••-----------------------------•---•...--•-•••--•..................••--•-------...-••••••--•--••---•---------.............
Nature of Repairs or Alterations Ansvreq when applicable_..__.._ . _.?______ __ . _ �.---'...........
------------------------------•--•-•-•---...........•--••-•---...--.....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of Iealth.
C qq
Signed.. ` ._��1..�...
D to
ApplicationApproved By--•- .-••-...••• . --• .---•....................................................... ......
Date
Application Disapproved for the follow' g re ns:----•-•-•------•-••-•-------------------------------•-•.........._..._..........._..........•••................
��
...............
I� Date
Permit No.......-- ------- - Issued..... ....................._....
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
f�rr�#ifutt#.e of (tium�rli�tnr�e
THIS IS TOC RTIFY That the Ind,vidual 5ewage Disposal System constructed ( ) or Repaired (�
by............ - �--- - -- -- Q.
........................................•-----••---•-------•--••--............... -
Installer
at............ ..-------•----..!; - .... .........
has been installed in accordance with the provisions of TIT 5 of h State Sanitary Code a dedcribed an the
application for Disposal Works Construction Permit No .... Q— ......... dated -------- %...c(b................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F. . -N. -C -T �O�N� SATISFACTORY.A!5
DATE....J0..1.�C..............
..----
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