HomeMy WebLinkAboutApp-Permit-ComplianceCLNo._ ............ --- v -• Fics.... ..4._v. _ ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Dispvs�l Warks Tonstrur#iun ' rrrnti#
Application is hereby made for a Permit to. Construct ('K) or Repair ( ) an Individual Sewage Disposal
System at: p „ of
.3.L..CU ......pl r.._.Q � ... �.,� .° .Q f'" 'c �............................... .. 5....-----�-V( l
Location - e or Lot No.
..C�� �..._... : , .c. ------------------------ .... •-------..._......... ........------_........
.. .. ...._ ... - ----
Owner A e
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling—No. of Bedrooms.._. �•___________________________________Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
_ Other fixtures.........---•----------------------------•----------._...------------- -----------------_-________-----___________----•------------•------------
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity_1_QS2Q__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 applicable ................................................................................................
Agreement:
The undersigned agrees to install the afor
the provisions of T I T 1Z 5 of the State Sanitary
operation until a Certificate of Compliance has b�
Application Approved
Application Disapproved for the following reasons: ..........
Permit No ...... L I — �8--------------------
V Individual ewage Disposal System in accordance with
tThen ed further agrees not to place the ystem in
b
;;
f i It .
�lM � 4 as q3
ate
------------------------------•--......... ...... _ •-------------
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Issued_.._ -- -• - -_.1......... ate ......
Date
THE COMMONWEALTH OF `MASSACHUSETTS -----
BOARD OF HEALTH
ham', TOWN of YARMOUTH
(Infiftrate of - falorntpitttnrr
THISjq ;2,4EIRTIgY, (flat the I�4iyidual Sewage Disposal System constructed ( ) or Repaired ( )
by........... ....................... .... -•-.............----........._._..............--------......... ........_.._...._
nstaller
at......... .......!•r•- _•!. --•---------------=----•---...--•--...---......•-•---•----•-•--- -- ...
has been installed in accordance Iith the provisions of TI 5 h State Sanitary C9de a des ibed in the
application for Disposal Works Construction Permit No ...... �� ��._.. dated_....l-d .� �.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS�WED AS A G AN EE;.THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. /�
C
DATE................. .................. ......................................... Inspector ............................... ----..._.. ...--•--------`................