HomeMy WebLinkAboutApp-Permit-ComplianceNo...._.l:! ..2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
00Fss.....
Appiiration for 11isposal Works Tons#rurtion trruti#
Application is hereby made for a Permit to Construct ( ) or Repair (4,�an Individual Sewage Disposal
System at:
...#..5:, rva-h!...1.�'r�-...w�...Y���rf�................. : �l g Vin- aS :................................
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Locatio -Address ---------------------------•-- or Lot -No- ----------------------------_-------------- --------------------- ------ ......
y� Owner Address/ �/
..---------•......... ............................•-••-------------- .0 ---.Te r✓..e Ptt/ /�,d.... . .....................
Installer Address
Type of BuildingSize Lot............................Sq. feet
Dwelling —No. of Bedrooms ............ ...*� 2...........................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures..-----•---------------------------------•------------.------•-----------...........--------------------------._........---•-----••--•-•--•...........
Design Flow .......... /40 ------------------------- gallons per person per day. Total daily flow ............ a.,512 .................. gallons.
Septic Tank — Liquid' ca.pacity.........._.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 ........................
-------------------•----..........................
..-----------. -----.._..........
Description of Soil--------------------------------------------------•-----•--••••.
----•-----------------------------------------------------------------------------------------------------------------------------------
Nature of Repairs or Alterations — Answer when applicable.......11�l?.(].....-v.419t...�4l .dr> .., � ....:_.
A-1.----- .....----•--------------------------------------•--•---...---------------------------------------------------......---------------.......-------•-------••------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 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 h h.
Signed..---- ��..--- ....................... ..% ... _._..
Application Approved By ••............. •••-••--•---....................................................... / %
-----•-•-
Date
Application Disapproved for the follow. g rens s: ...................
................•----•------.........----------------•------------•------..........-----•----------...--•--•--.............-------•---............
q �2
Permit No ............. ... -................ Issued.........
Date
............................
— Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tatifiratr of Toutpitaurr
THIS IS TO CERTIFY, That the Individual Se •age Disposal S7stem constructed ( ) or Repaired (✓f
by....................................................... ...Lr.T•--.....-----...........................--•--•--------•---.._........_
Installer
at...................................... - ... .......................................... ...............................................
has been installed in accordance with the provisions of TITIEo e State San' ary Cot . a escribed in the
application for Disposal Works Construction Permit No......Q `......::........ dad......... b ......................
THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILLNCT ON SATISFACTORY.
DATE... .....:.:...:� Z -................................ Inspecto . �... ............._