HomeMy WebLinkAboutApp-Permit-ComplianceNo. Fis.....Z .. r...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonotrur#ion 11trntit
Application is hereby made for a Permit to Construct ( ) or Repair ( V,<an Individual Sewage Disposal
System at: LD7 T M A P
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Location - Address -- or • Lot No.
-'•-�'/./V�..ytS.d--- Owner.... - - ^. ............. .... -' Address ....._. .............................
r�....... `-.rz. `Fu ktZ�e►J...._l ct,:1 A� Oil- l
............................................................................ .... • .._.. ........ ....�,..............
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling —No. of Bedrooms ........... 'W_0 .....................Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Building No. of persons ............................ Showers — Cafeteria
G4 Other fixtures -----------------•-•...........--•......_---•-
W Design Flow ..•..._..___._ /'./-(1-.•...............••..gallons per person per day. Total daily flow ........... &Z.A.0.................... gallons.
WSeptic Tank — Liquid capacityjdv. a.gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
3Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
zj Other Distribution box ( ) Dosing tank ( )
~4 Percolation Test Results Performed bY.......................................................................... Date ........................................
,aa Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
G4 Test Pit No. 2 ..............; .minutes per inch Depth of Test Pit -------------------- Depth to ground water ........................
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0 Description of Soil ........................................................................................................................................................................
W
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U Nature of Repairs or Alterations — Answer when applicable ... AJ,6 �.1.._ 4UPrICe-----J00V .�aS7-:.....
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LITLL 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 ealth.
Signed__ -- C' .......... ............. ...................... ..... . �.q ... %�....
Application Approved BY ........ .....•--•-----•......-----.. _ ...........
Date
Application Disapproved for the following reason .-----•..•.-••••-••--•--•-•-•••----••----......-••••-•-•--••.........•-•••••--••-••-•••........................
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q� 'Date
PermitNo............................... ..... Issued_....... -'- ...:_.......................... ..
D
THE COMMONWEALTH OF MASSACHUSETTS T
BOARD OF HEALTH
TOWN of YARMOUTH
(Irr#ifirate of Tompliana
THIS IS TO CERTIFY, That the Individual Sew a Disposal S7stem constructed ( ) or Repaired
by....--• ..................•---•••---•............. -. ... _...........-•-....----•--•-•-••-•..... .-• --.---_----_---......... --•----••-
natal er
has been installed in accordance with the provisions of TITof 5 T1eState Sanitary Code as escribed in the
application for Disposal Works Construction Permit No.._...:�' Z --....-. dated ....
.i�i..Q...............
THE ISS ANCE PF THIS CERTIFICATE SHALL NOT BE,.CONSTRU A GU N E THAT THE
SYSTEM W L F OTIO� SATISFACTORY.
DATE:.... ........................ Inspector- .._...................