HomeMy WebLinkAboutApp-Permit-ComplianceNo . ....1.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Murky Tonuirur#inn 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair (4 -Tan Individual Sewage Disposal
System .11�..:t..1...z------------------ .ze'&Z W_z ................. ..m P.- ...._:
Location - Address.................
ddress-•..-• or Lot No.
..�.�.c.../8a�...........................................................
Own r Address
,W� - f 4 - J" Cd�!l!1 _�� • '��. ..... ......... . .. . ----
Installer Address----- " ------------- ---•------•-- -•
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .. ..... . .. ........................:Expansion Attic ( ) Garbage Grinder ( )
p` �, Other — Type of Building . ..... No. of persons ............................ Showers ( ) — Cafeteria ( )
a Other fixtures .---• ..................••---•----....-----.....
W Design ` Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ---------------- Width ---------------- Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area -------------------- ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0.4 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 ........................
R++---•------------•-•--------•-------------------------------------------•----------------------- ------
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0 Description of Soil ........................... .............
W•-----•-------------------•------•-•-•-••-� - - _......_:__.......__....._..._..._..__....._..
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UNature of Repairs or Alterations — nswer wh n appli ble.__._ __.. =_l._ �%%1P.... !!� /--------------------------------------------
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Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi: 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 th board of health. /
el
Signed.. = ��.-=------------- --- /- ..... _........
Application Approved By .... _.. ' Date
�r
Application Disapproved for the f ollowing reasons: ...... ................................................................................... I ................... .
.............................••------•....--•-•••----••.......----•-•--•------------••-•----•-•--.._........•--•-•...------..........--------------•-•--------•--........_.................--•--.........
.� Dau
Permit No. .... .! ... ..
._.... Issued.-- - / ~ L .....................
Date
THE COMMONWEALTH' OF MASSACHUSETTS'
BOARD OF HEALTH
/ TOWN ` of YARMOUTH
(irdifiratr of Tontplin rye
Tj.S CERT Y Thome Individual Sewage Disposal System constructed ( ) or Repaired" (Ae
by -....d .:.1:. /4C0 .��.....-vC.............. ..........---------•.... ..........
p '' / f Ws
at--.7�...`1 �.d...... f f�.�?U '^11111 .------. �-----------------•-----...------....------...............------------..............
has been installed in accordance with the provisions of TI -E 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. �%-1..� �..................... dated...... ........ .-.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU CT ON SATISFACTORY.
DATE.. .... 7 .s . `/ ....... .. ......... Inspector...... ...........