HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Application for Disposal Works Ton#rur#ion jhrmit
Application is hereby made for a Per it to, Construct
System at:
Location - Address
Owner
-- .... ..C__... .....................•--- ---......--------•-----------------------
Installer
Tvne of Building
( ) or Repair (r/f an Individual Sewage Disposal
or Lot o.
Address "
Idik'arl4e ..
Address
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .......... Q......................Expansion Attic ( ) Garbage Grinder (
Other Type of Building ---------------------------- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .............................................•--------...---------•--.................---------------...--••--....------......-------•----------------
Design Flow ............... /.J4_ .................... gallons per person per day. Total daily flow ................ Y.4._O................. gallons.
Septic Tank —Liquid capacity.-1.'5oj7gallons Length .:.............. 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 ........................
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Descriptionof Soil ............................................................................................
.........................................................
Nature of Repairs or Alterations
z:a.... G C.4....QJ.4-�
Agreement:
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Answer when applicable ...... ru
jX0.0-- 4..5?.-"..
Theundersignedundersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of I ealth.
Signed.... 1 � - - �--•--•--•-----.•---
ApplicationApproved By---- . -•--- ..... ........................................................... ........
ate
Application Disapproved for the follo ng reaso-........................ ........................................................................................
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Permit No..... �� �'-.--- S
-' -�........................... ISStled..---------- _• - -•------ ^ �, Date ---...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH \� _
TOWN of YARMOUTH"
Trrtifiratr of Tontpfiamr
THIS IS TO CERTIFY, That the ndividu Sewage Disposal System constructed ( ) or Repaired (14
by.............................•---------•---.._..........._..._...... : C. ....----------.....---.............---------.........------.._......................................--•-----•-
f/ Installer /
at....................................... .�.y....4.`. _6dj ..a'7_ ........w �.......u,4�F.•�os1f`�---........------...---------•---•---...-----------------..........------
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.... s '. ` C; ................. .-dated ........ ...................
THE ISSUANCE OF THIS CERTIFICATESHALL NOT BE-CONSTRUEb AS A:GUARANTEE THAT THE
SYSTEM WILL FUNCTION, SATISFACTORY.
.. .... ..........--_. --.. Inector..� : .�.....�... `........................
�DATE.. sP