HomeMy WebLinkAboutApp-Permit-ComplianceNo . ........r.. Fsa_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Applutttion for Disposal Works Tonstrttr#' n 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
..__....... -.
Location -Address
---. L......_..t.............. ..•----------•------- - -•--
owner
Installer
Type of Building
ko-r 840M g o
------------------------------------------------- _--- -------------
or Lot No.
-................................................... ..........
wt c L' Address
--....--• -----------------------'.'.Y...........-----------•-•---------•...........................
Address
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 ..........................................................................................................
.._.....
V �------: --�...
Nature of Repairs or Alterations —Answer when applicable_________•_ _.... _.._._._....._.....�...--.---------..
.......................................................... `Syl/`
Agreement: Vu ->r S {4e,+y Se -1 S 2 yy� V 1 ice^ S %`C `�C 1
The undersigned agrees to install the afored6scribed Individ�Sewage Dispo-SA 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 issuueeddbb he a rd of health.
SignLc ......................................................,
D e
ApplicationApproved By..... ... . .. .. ........•---•-----•-----------..............-•----......------•-----•.. .� �...._....
D
Application Disapproved f . e fol o in reasons: ..........................................................................................................
Permit No. ------•.....1- - h ............. Issued........-, - ----
.............. Date ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Terxifirate of 09outpfitturr
�f
THIS IS TO CERTIFY at the I id Sewage Disposal System constructed ( ) or Repaired (�
by ............................................../........ ._..- .. ...........................-•------........-•----............--•--•------..._........._..._......
. . ..........
�+ Installer
at ............ � ..... �� '?G'Gt - _ <�!v�.1. - .................... ��' - ` �"`-iG�2�......-•-----------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code a d scribed in the
application for Disposal Works Construction Permit No.._...� k.:!7 ` dated -� ." � .�........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS U ANTES THAT THE
SYSTEM WL I
FI.KNCTIONS TISFACTORY
DATE:.:..:
..- ................................... Inspecto - --•-