HomeMy WebLinkAboutApp-Permit-ComplianceNo.. ...�� Fss_..... .._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Disposal Works Tonstrurtinn 111erutit
Application is hereby made for a Permit to Construct ( ) or Repair 0< an Individual Sewage. Disposal
System at: Gj_
14-44 L`� Af Location Address" ... ;-% 'L.._..... Y :........yLot /i /L4'\..
...
Owner L✓'�`� y � Address
a ... .. c { � I A n1 S3' 71v� .AL1 P GtiS .
Installer Address
Type of Building Size Lot ............................ Sq. feet
a Dwelling —No. of Bedrooms-
-�--- ........................Expansion Attic ( ) Garbage Grinder {—�- /SIO
p , Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures .....-•-•---• ..................................... ..... .
W Design Flow ............... ......:.�...�.............gallons per person per day. Total daily flow ............. ..... d ..................gallons.
WSeptic Tank — Liquid capacity Z gallons Length ................ Width :.._..._. Diameter .......... ...... Depth ................
x Disposal Trench — No. .......... 1_....... Width.... .... .......... Total Length ....._....... S.. Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet....:.t. . Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ................ ....... Date ....................
.-:.
as 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...--...................
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0 Description of Soil..................•--•-----...........................-•--------.....................--•-----...-----•---...----•-•------------•--...-----........•.....................
"W
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W•-•----••••••......................•--••----...-•••--............-••-----•---••----•-•---•-----••--•---•-••----••---••-...._....._...... .....
_............ ....
UNature of Repair or Alteratio s — Answer when applicable... -----"`--- --- .=3 -�` .. L .........
f•---.... ......... ......_... -.. ................
Agreement: j
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.t'� 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss d by the boar of h lth. r
Signed... -----.::; .
Application Approved By...
Date
Application Disapproved for the following reasons: ..................... .............. ..........._.._......-----.............---------......._......---........
.............................................•-............................................---...................-----•--------•---......-•--•---..._._.._............................................
_ ..............................
Date
PermitNo ..... .........._.........------•- Issued.---.... . .... ..................
-'ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(n ifirtttr offaaaut�rlittnr�e -
THIS IS TO CERTIFYTlig the Individual Sewage Disposal System constructed ( ) or Repaired 0
bY-............................................. .Cl.1t l..q .... :!�?.�? !lv '' . !U.' �..... -- --• .....................a....... ...
.. .....
Installer
J�p W �i1oEv v-,
S14—
at...........................................................7-----••. ....----..._...P _7... - ._ •--•--.0.0.. - ......................
has been installed in accordance with the provisions of TITI, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..` S ...... � �6............... dated..... 3�_ G�F. __......_..........
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. DATE ..................:.:` .. .1.... ....................---........... Inspector.....•-• -. -....-�.,Z,�..