HomeMy WebLinkAboutApp-Permit-Compliance82=164 J 5 00
No.--- ----•-----------•-- Fps ..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....------....TOWN ............... _OF .................. YARMOUTH ----------------------------------------------
Appliratiou
OF..................YARMOUTH--------...-----------------------------------
Appliratiou for UiipoiiMl Works Toustrurtionami#
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
........................-C I.-- _------ _
Location - Address
Owner
......................K
Installer
or Lot No.
Address
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 ........................
Descriptionof Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
-•--•--••-•--•---•-•-------•-------•-•......------••--------••--•--••-•--•--••-------•--------•-•-•---•--••----•-------•---------•------•------------•--•---••-----• •---------•-------------•-•---------
-------------------------------------------------_--------------- -- -------------•--------------------------•----------------------------------------•-----------------•---•-•-•-•---------------
Nature of Repairs or Alterations — Answer when applicable .-----------------------------------------------------------------------------------------------
•------••---------------------------•--------------------•--------------------------•-------------------------------------------------------------•------•----------•--------•-••--•-•................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL Z 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha b n issued by the b rd o a .
S✓ ------------------------------ •-• �-'��•` ----..
te
Application Approved By. •` •--...--•---------------- --- - -.- •-
----------
Date .
Application Disapproved for the owing reasons--------------------------------------------------------------------------------•-----------•----------..........
PermitNo ------- --------------•------------
Date
------- ---
Issued .. -
Date
'USr
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................TOM........ OF ................. YAMODTH ...........................................
upirtifiratr of Tomptiatty
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by----------------- 9.- B .H_y....JbIC-.---------------......--------------------- --------------------------------------------------------------------........-------------•------------
Installer
at -------------------9--- CjUIELOT --- Rj0A 1-i- Y W.T-w....-------------------------------------------------------------------------------------...........------------------
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 ........ $2--l-64 ............:... dated ---------- 7./-1./..$.?2---------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector