HomeMy WebLinkAboutApp-Permit-ComplianceNo. Fzz....... ....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal Works Tonstrurtiun Vprrmit
Application is hereby made for a Permit to Construe
SgstgmQat .._.._ .... ................
-.•.--•. Location - Address
. . ....................................••--•--.-•--...
Owner
Installer
Type of Building
Dwelling — No
Other — Type
Construct
( ) or Repair ( 1 an Individual Sewage Disposal
.......................... .......:
or Lot No. M ) p �3
Addrdpkj
11)
Address
Size Lot ............................Sq. feet
of Bedrooms ............ .........................Expansion Attic ( ) Garbage Grinder (AJO)
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. I................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.......................................................................•--•----.-.....-...---------------------..-.-.....---•--.....-----------------._....----
-- ------------------------------------------------------------------------------------•--....................
..................•---------..........................•--•-----............----------•............-•----•--...----••--------------- - -
Na Repairs re of Repa or Alterations — nswer when applicable-_,..�C.2sSa1� `I ?.......... ...�adl.-1L.............
... dS}4�_. f.' �1 ? .r ...::.._ „t.._._S Q7!-Q•� XIS�i s�_ .1�l._�_. ! e. ......................
Agreement:'W GW�'%�
The undersigni�'-agrees to install the aforedescribed 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 issued by the board oflWalth. p,
Signed............... .............. ....
ate
Application Approved By....
Date
Application Disapproved for the following reasons: .. ............ ......................................................................................... _..
�- ........ ........ •.......
Permit No ...... � .--...5. S ................•--•.... Issued -............................Date
Gj.7 ......-----•-•--•
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifirate of faompiittnrr
THIS 1 TO CER IFY, That the Individual Sewage Disposal System constructed or Repaired
by......-�a-- ... �.�4.U. � � ✓t.�.... .- ................•...Installer __... (/� �%�7 ,..... �� T � ...... ............_.........r...............
at :. . -�/ ...................
... ......
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ `!y.-.Y-�................... dated ...... y.. -!__-.9.._Y.....................
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. :. 7.. ..................... Inspector. . ' ..�;� -G =................_