HomeMy WebLinkAboutApp-Permit-ComplianceNo..9."-5-20 5 Fss..... 2.:5 ..... _.....
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion rrrutit
Application is hereby made for a Permit to Construct
System at -
....2-7 1 A L4914. t---------------- -------------------
-Location - Address
....z:N!.ils_....,1...-•-------------•-------------.....
Owner
.......................................
Installer
) or Repair an Individual Sewage Disposal
07 ;Tz -2-- MAP -4-2,
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or Lot No.
-•----•-•---..p ..- ..
-----------------------------••-----......---...----..........---..............--
Pc.o.,& A...�42.... dre.�LaU ��........
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms...............Z........................ Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ................•-------•-----------•-••---•-•-----........-•--•----.....--•--.......-•------.............---.....-•---..........•----------....------
Design Flow..............5.5..... ...............-gallons per person per day. Total daily flow......... ZZO ...--.................gallons.
J.
Septic Tank — Liquid'capacity C?� gallons Length.... -...4..`.: Width._. ..r_...._ Diameter ................ Depth...-?........
Disposal Trench — No. ...... /............ Width_t................. Total Length.... Z ...... Total leaching area ..2-23. -------- eT.*.0 -J"
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( K) 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 ........................
Description of 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 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.
Sign j!I`
�+ !Date
Application Approved By.... .... (� _
... ... ....... ----- """""� -•----... ._..--•----•^---'- Date-- ----....
Application Disapproved for the following reasons:
............... ........ ......_.._.. l/........ +r. _- �'�_ ...Date--------------
Permit No ......... .^............. Issued. ...... .. Date
� .. ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifirate of Toutpliatme
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by---....T f1,4,�......,r .G.. ,c. .7.:....................•--•---•----...............................................................--•........................
Installer
at.... �7.. fi ka.-•-------------- ------_............----------------------------•-•-•-•---......---...--------..............---------
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code s des ibed in the
application for Disposal Works Construction Permit N .. dated ......
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT .@ CQNSTRUED 81 G� RANT E THAT THE
J. SYSTEM WILL WNCTI` N( SATISFACTORY.
i s ' --
DATE............ ;2.i.,..�F.?.. `1r.... ................................. Inspector......:. a" �..., ...`:�::..........._........---..............