HomeMy WebLinkAboutApp-Permit-Compliancer N ,
No..............
.. Fas.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrnr#ion Vrrrntft
Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Individual Sewage Disposal
System at:
---_-•-_.:. u�&:. D�................................
._......
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Lddreo s
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Owne
Installer
Type of Building
Dwelling —No. of Bedrooms, --.2 ..•_. ._._.
Other — Type of Building ---------- ...........
Other fixtures ............ ...............
Design Flow ..................................... .....gallons
Septic Tank — Liquid capacity.__ _.__gal s
Disposal Trench — No . ............. ...... Wiii __.__.
Seepage Pit No ..................... ameter.__ ..._
Other Distribution box ( ) o
Percolation Test Results Performe by.. -
Test Pit No. 1 ................ inutes p r inch
Test Pit No. 2 ................ inutes er inch
Description of
Up f-AnE
w•--• or Lot No. ".'.__....................................................
-.............Address
Address
Size Lot ............................ Sq. feet
-.Expansion Attic ( ) Garbage Grinder ( )
o. of persons ............................ Showers ( ) — Cafeteria ( )
per p rson per day. Total daily flow............................................gallons.
Le ---------------- Width ................ Diameter.--------------- Depth ................
-- ----- Total Length .................... Total leaching area ...............--..sq. ft.
Depth below inlet .................... Total leaching area .................. sq. ft.
tank ( )
........................................................ Date ........................................
of Test Pit .................... Depth to ground water........................
of Test Pit .................... Depth to ground water........................
Nature of Repairs or Alterations —Answer when applicablQol __NI.._.7� Adak....._`_ w ............
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 been issued by the board of health.
Signe........ / .,a./ --- ...................... //l.. ..�...
a
Application Approved By .... . --- .............. ...........................................................
Date
Application Disapproved for the folking reasons: ..............................................................................................................
............. i Date ._........�
Permit No... • - .l.T -----------------------• - - Issued......... . ................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifiratr of T-amplittnre
THIS IS TO CERT That the Indival Sewage Disposal System constructed ( ) or Repaired (!/�
by........................................... . •%:--.(.,,rp. .....:............_...... -- • ... ........._
._......... ....
/Installer
at------. cZ.1 ------ ..... Y1 1 �• !t- ............ 41..1 .......... ; p ............................................ •----•------ ..................
been installed in accordance with the provisions of TIT 5 of The State Sanitary Code §2desc be in the
application for Disposal Works Construction Permit No ......... . -"__' . ................ dated........I....-.... ... d�..._._.__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.-.' --• .............................................. Inspector ._. ..
...._..y