HomeMy WebLinkAboutApp-Permit-ComplianceNo.!?-� "_ - - Fss..Z
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrur#ion Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( 14 an Individual Sewage Disposal
System at : w
cLocati Address / or]Lot No.
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-------- -�' .... ---.--.-------....----------------------------
Owner Addresssc ` .......
.(`'�--------------- a P I> 1...cu.--• v �` i--- 7-.----- �i. :.....
Installer L Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 460
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.i� ......gallons Length ................ Width ................ Diameter...--........... Depth ................
Disposal Trench — No. .................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No... A ................ Diameter. C X........... 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 ..........................................
-tt----------r .........--••• ........
Nature of Repair or Alterations — Answer when appli.... All ...... .... ... 4 fi �✓`-_.(r,.i..�__...1. !! __.
._...... e- s--------- ---------------------------------•---------------------------------....--...----------....•...---------------...........-----
Agreement :
The undersigned 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 b n issued by th health.
Ined
�� 1 at
Application Approved BY ...."-------------•-- /�1�C
Dat
Application Disapproved fav he following reasons:--------•-----••-------•----------------------•-------------------------------------------..._..------•-----..--
----....•-------------------------------------------------------------------------------•----------------...-----•----...............--------------------------------------------------------------.-•---
G Date
Permit No ...... 4F...Z.-• 2!,��....................... Issued ...........a 7.y ................
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
f9rdifirate of Tomlilittnrr
THIS I$ TO CERTIFY, That the Individual Sewage Dispqsal System constructed ( ) or Repaired (t4l�
by........ ......•..................................•------------•---................--------
Cr — Installer
at-----• J_.___t11�_1r.1�nG......_.^xr..... r^f�`st1� ��-
has been installed in accordance with the provisions of TITLE of The State Sanitary Code as described 'n the
application for Disposal Works Construction Permit No ...... ----j11-- ----------- dated...... �._,.� _.:;y` ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
C
DATE .................. f,2---_2--•----------�------------------------------ Inspector ...... �-=-•------............
...._/i