HomeMy WebLinkAboutApp-Permit-ComplianceNo...% F�$_.........._..........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -OF HEALTH
TOWN OF YARMOUTH
Appltration for Disposal Works Tonsirixaton 1 rrmtt
Application is hereby made for a Permit to Construct ( ) or Repair K) an Individual Sewage Disposal
System at:
L Location Address J . � t No.
-.-••.___._.--- ..--••••- -
Owner Address
urJ l0� v1.Y�1��t�.. t�-N 14-
� _-......_.. d.
....__.... .-•- - -AZ
•••--•-•----....... •••-•-•..... ...._....... .. ................
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 ( )
Other fixtures. -
Design Flow .................... .......__gallons per person per day. Total daily flow__._._....�0._------ ............. gallons.
Septic Tank — Liquid' capacity.4102Agallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ....... Z......... Diameter ..... ZO........ Depth below inlet _._.....4.._....... 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..._......I ...... minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil ..................................................................................
----------------•--•--•-•--:•--•-•-----•----------......-•-•--------•---•----------...._....----••-----.......------------..................-•-•----...........--•-•------...--•-•---------•---....
Nature of RRpairs or Alterations -�j Answer when appli ble___yl :_. '4...._.1 0 ?Q„c !'7,� • i •�i�
. .?... ..r.._.. ...........
`...................
._.. �.. .. G.3�a �,; aa•►�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Com liance has been issssue b the b arA o alt
Sigf c --------------------•- •............ ..... `D�a`eSy----•-•
Application Approved By..... •-•-......... ........... •-- --•........................ ......,S -
at 3
Application Disapproved f the following reasons: .. . .................... ...............................................................................
.........................•••--.._..-• Ge:.J_ `............. .......__......_... :� L .� .. Date.......- -'
PermitNo...... ...................... Issued......... .... »�"'”` ..............
Date ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irr#ifutt#r of Tomplittnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (/
by.........................................��..7.:?S. c .v ,•� C Q} ,ySTlLc�c�-7 a ►J.....-•-- --................_.................................
�
at ...................................................... 'rInstiller
•-•--
...............��:.......,......a.. ............
._.._...
has been installed in accordance wi�
th the provisions of TITLE 5 T e State Sanitary Coas escribed in the
application for Disposal Works Construction Permit No ......
_ ' .._....... dated..-. _ . e .�;._ C(_.��". .................
THE ISSUANCE OF THIS CERTIFICATE. SHALL NZT BE CONSTRUED AS A RAN EE THAT THE
SYSTEM WILL F( CTI SATISFACTORY.
'�
DATE.......................... V. ........_..........-----.......... Inspector` �. +� ...... ........
�I � � ;� •�..._.-..,-t'<' � .�� .. � �t •� � • �