HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Warks Tonstrurtiun f ami#
Application is hereby made for a Permit to Construct ( ) or Repair (jaj an Individual Sewage Disposal
System 15..L';�.nL1............................. ............ ........................... Lod ...2q3 .......•-•...MR. P q.Q ....
7�Location - Address or Lot No.
.....�i�.... �»»..?0�.. I.Y.tiJ......................................................... _...»�._......!..... N l0...I 1.. ..................................................... »........
Owner Address
...._t� EI- .. CQ s . ...................................................... --- c� = =�Q� z3�--------Ce—A)'�=�2 vi//�..........__..
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-------------------------•---------------..............------•--------..............-•-•------------------•------•---•-•---•------------------........
Design Flow --------------------------------------------gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity............gallons 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...—]o ..---....------...................... .... ..._.-............ '°``''Q-----...----------......----------------------------------..............
•-----------------------•----.....................-----------------...............................----------------------•--•-•----------------•---.......------•---.........-------------------•---•--•
Nature of Repairs or terations—Answer when applica.ble..._1__z�sT-00........... "'.!F --- -.Ifo4a.... .............
SEP! S: 53 aims ..............................-N oa v_oop t` wL
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Agreement: Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 health.
Signed....`. a C'" ................. ----
D try
Application Approved By ...... . ... . -• --....................................................... .........5`..4! .=6,1
Date
Application Disapproved for the follow#g reaso�s:..
Permit No ............. I._ IN ---------------»••--
.•................................•-•----•----.....----•------...........
------------------------•.....-.-.......----..................---........
Issued_ ...... � _...? .. •-----»Date ....»
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrfifkab of Team rfiaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (1-1
by..........t.- -'T-.•. r q W. s......................................................................................................................................................
Installer
�!��2
at ---.....Q. 2 �Z� c �c,S o.;`_... .. -•--- ..._._..................
has been installed in accordance with the provisions of TITL of T State Sanitary Code as c scr'b the
application for Disposal Works Construction Permit No.........................._:-.-�........ dated .............. i/ ...�, .- ._...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARA TElE� HAT THE
SYSTEM WILL FJJN TION SATISFACTORY.
DATE....... _// .............................................. Inspector.....»`...-:.... ....... ........................................................