HomeMy WebLinkAboutApp-Permit-ComplianceVOL
CD
No..... 9
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,,��,
TOWN OF YARMOUTH
Applutttion for Disposal Yorks Tonstrudion lirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage. Disposal
System at:Yl
... .... .... .. ..
-•-.••--- r Location - Address--- or Lot No.
.....kl`.►�c.t%s.�:----...•..........................................•----.......•----.............--•--•-... ................................. _........
Owner ••• ' -• . •Address
W .... .........................................................................
Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms...........................Expansion Attic ( ) Garbage Grinder ( )
p� Other — Type of Building ............................ No. of persons....... 2................ Showers ( ) — Cafeteria ( )
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 ...................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 ........................................
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........................
a
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0 Description of Soil...............•----............---...................--•---...........................................................................................................
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•-•----• .........................-.. •--------------------------------- .......
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W.......................................................................................................•----•-•--------...----------•-..............----------.....-----.................-----.......--
U�4 Nature of Repairs or Alterations — Answer when applicable_.../.V4.T�..;.........M. W......ir a .Q....yet 1 731JA—
...............................�.a.QQ....g A......)91-r...�.,. ::ti r�, ............................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLi: 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 healt
Application Approved By ...... ........•--- .-- - - C
Application Disapproved for the f oUowingireasons:
Permit
'--,.'----.... ....... t :
Dat
..---•----------• ................• •-----.................................
.-- Date
Issued.......... ... -�. .......
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Intifirair of Tomplinurr
r` THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by............ ............I xt.-..0.4w.441....••.......................•-.......................................••-------.................................
Installer
at ....................... .. .......... G..!- .aa. d(_.......--- .A.........-
...----•---------.........------..........--•-...... .....,`.............---- ..........
has been installed in accordance with the provisions of TITLE �f The State'Sanitary Codeias escribed in .the,,
application for Disposal Works Construction Permit 1�'0......
....... . ��: '..�.` dated.._.....
THE ISSUA CE OF THIS CERTIFICATE. SHALL NOT ( _CONSTRII A 4A,,G.UAR9�4N EE'ftiA' T4
SYSTEM WILL NC ION ATISFACTORY.
�...---•--•................ Inspector '` -..'i..�.......`'` ��...�:....�.DA E ' y ...�:.