HomeMy WebLinkAboutApp-Permit-ComplianceNo....l..--........ Fps. /S oP
THE COMMONWEALTH OF MASSACHUSETTS
ti
BOARD OF HEALTH
TOWN OF YARMOUTH
Appitrattun for Disposal Works Tonstru tun Frruttt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage. Disposal
System at: L07- F/— /
Location .Addy r Lot_No. � •-.
................. 's ... a..:...---........--_... ....��.._.< ,r ..
Own dress
3TC `
a -------- �---..................................................... .......... . ' � ... .._----.
...
pq Installer Address
6 Type of Building Size Lot ............................ Sq. feet
U Dwelling —No. of Bedrooms ......................... _....Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons .......................... Showers — Cafeteria
ad Other fixtures----•-----•----•--•----------------------------
-----------------------------------
.
W Design Flow ............................................ gallons per person per day. Total daily flow............................_...............gallons.
WSeptic Tank — Liquid ca.pacity............gallons Length ................ Width ................ Diameter................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
,1.4a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water ........................
f= Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
�Y.......................................••-••...-----•---......---••-•-•-------------------..._..........................--•-•------.......---................
0 Description of Soil ........................................................................................................................................................................
W
V---•-••.................................•-----------------•----••--•--•---•-•--------...---------....._..........•••........ — -------------•-------.................----------•------
W ,w
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--•---••..............................................................................••--••--.----"--.------_....__...._....
U Nature of Repairs or terations — nswer when a icable._ ..+ ' -...,'� �.......�... .ks '
5.A - . _9 _ _ .� fir-• ..::::::::..: .
Agreement: /
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is b the board o health. _
............. ----��---..............--•----....... .........� :�.�.�„.���
Application Approved B ........................................
Date
Application Disapproved for t Vfowin reaso s:-•--•••••------•-•................•-----•---•••....•-•------•-•-•-••---•-•-.........-•---.........-------......
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Dau
Permit No......./. `.-. .. �....- - ......... Issued...........-.�d `r ..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Urtiftrate of Tompitaurr
THgLZ4S,T,OCFja" IFY, Th the d� idu Sewage Disposal System constructed ( ) or Repaired
s _
Inst er
at ........ �.;�..�r s f . ......= ................ .
been installed in accordance with the�provis" ions of TITLE 5 of The S to Sanitary Code as described in the
application for Disposal Works Construction Permit .................. dated..... -------.__---.--.---
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE
-...�., .......................................... CONSTRUED
.RUED VU AN'�T..EE THAT THE
SYSTEM WILL FUNCT'I SATISFACTORY. ctor. Ins e.................A...........:....�:.....: . ...DATE..•----.