HomeMy WebLinkAboutApp-Permit-Compliance•___e_ 7.�, No....L.r ...... FIcs... �`' _® .._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Applirtt#ion for Disposal Works Tons rur#ion rami#
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at: n M
..lq...ks2..s..................................................... �a:.......................-•--•----•--...»....--
Location - Address or Lot No.
Owner Address
r ��o.� ���-x �G2xtC ! r _. 2_1.��/S .l�!,1......Y%?r.�. '._.._....................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms ..............:!` ---------_-------..._--Expansion Attic ( ) Garbage Grinder (jG)/i,d
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----------------------------------------------------------------------------------------
.---------------------------------------------------•----......-----------------------------------------------------.....
--------------------------------------------------------------------------------------------------------•....--•-----•-------------------------------•-....--•------------.........._.........------....
Nature of Repairs or Alterations—Answer when ...................
L_---------------------------------------------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLr, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isb3 the b94rd of health
---------...-
--��°.- ...5�
Date
Signed...
Application Approved By.
Application Disapproved for the following reasons:..................
Permit No�-�- - 2
. - ..................
Issued.-------- P ............................
ate
Date
---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS —�
BOARD OF HEALTH
TOWN of YARMOUTH
(Irr#ifirtt#r of Tontplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired Y-,-,)
by.... --.....T........................................................................................................................ -
Installer
at../ ..e .i f= ......l- ............ .._. !��1?/: 1I__ :.._....--•-------•----
has been installed in accordance with the provisions of TITLE 5of The State Sanitary Code as described in the
application for Disposal Works Construction Permit --------------- dated___::.!...5......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _ �
DATE ............................................. Inspector... r / /�%F �k �