HomeMy WebLinkAboutApp-Permit-ComplianceNo.f)....3?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion lirrmit
Application is hereby made for a Permit to Construct ( ) or Repair (A4"'an Individual Sewag�„�ysp al
system at:
=1rra•s-Lo s .
v v �. ddress
Installer AdcFress
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
rk Other — Type of Building ............................ No. of persons ............................ 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 ........................................
a
Test Pit No. 1 ________________minutes per inch Depth of Test Pit .................... Depth to ground water ......................
L=, Test Pit No. 2 ---------------- minutes per inch Depth of Test Pit .................... Depth to ground water ........................
pG.............................•.........•-----........._..........--•--•------•--•---......_..................___..._.................._......................
0 Description of Soil ................ ........................................................................................................................................................
U-, -------------------------------------------------••----------------•----•-•------•••---••-•- ------•-----------------------•------•---------•-•-•---- -- -_.___------•----•---...
Nature of Re airs or terations — Answer when applicable.__.f i �C .. ,t;� ..._..:.a _...._�.:)A C........
...: �� ......._. ..-. �.-......•- .�_ � � `..........•..t------ i 241 � :=•---- ----------------
Agreement :
The undersigned agrees to install the aforedescri ed Individual Sewage Disposal 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 iss y the board of health.
Signed. ...... --------------••- .... _ -
Date
Application Approved By.....hfo
..... -_..._..••---..........--•---•--............ �C
...._. _... Date
Application Disapproved forwin easons •-------._......-•..............................•-----•----............._......................
-•------••.....................•----------- -........._..._..._..•--•----------..._....-•-..........._••••--------
C�.__...--•-•-•-.....----------._...........----...._.........----•----...-----•----•-••-
' Date
Permit No......... ! .......-�--4-------•---._...... Issued...... -9-- •j -- - •----
- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifirate of faoutplinurr
`- THI S TO>CER Y, That the ividual� wage isposal System constructed ( ) or Repaired
by......... 5..... . �? ..:........ !!� :�.__---=---•!.. -=•..............•---................................._......................_...._.....
%,r, / al frl�i
at- ...' ._ ....ie�a G?� .....e.:....... In: .. __._._._ ' ►1< .__..._..... ...............
has been installed in accordance with the provisions of TIT 5 of T tate SanitaryCode as describedin the
application for Disposal Works Constructin Permit No ...... __ ._ . -__ ._ dated ......... —► ^" [Z ----••-
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT- BE, CONSTRUE"IS A,0UARANTE9 THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
Inspector
DATE...........ti. {., ...... +....:....................... .....::.... =, .......... '................_ .............................
t