HomeMy WebLinkAboutApp-Permit-Compliance5� �e
No._:.2: 26
Fss...1.. _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH $
Appliration for Disposal Marks Tonsirnrtion rerun# ".
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System:.S.G.a,.l ..Y — .��.... ....--........... .......---�t5/ 1 k...... _�> �,............-
-- - - -- --.................................
Lo ion -Address o o.
..........Q- __�!�� ...lAS �. _ �✓ .... ..................LSU ....... . .. .................._......_.
_ .._.
W O�wfiyr J ( , f Address r
a......:........... . - ----......................-----•---------•---....._.........---------------------................
Installer Address i
Type of Building Size Lot: ... t�J` �? - ___Sq. feet
U Dwelling —No. of Bedrooms .............. .. .............. Expansion/ _Attic ( ) Garbage Grinder ( )
aOther Type of Building _..l cfS i ,l........ No. of persons.-, ----- 1. _'................ Showers ( ) — Cafeteria ( )
dOther fixtures ...........................................----------------------------------- ----------------------
W Design Flow...................G',rz..._._._.... ga.11ons per person per day. Total daily flow..__._...___.__�5.d............... gallons
i
WSeptic Tank — Liquid' capacity -�Q� ...gallons Length_�J_____�___ Width_-1-_�Q___ Diameter ................ Depth__~____= .._
x Disposal Trench — No . .................... Width .... T. ............. Total Length -______ ___I........ Total leaching area -------- ;........... sq. ft.
Seepage Pit No --------- I........... Diameter ..... /.0.......... Depth below inlet ... Total leaching area.Z.4a_Lsq. ft.
Z Other Distribution box (x) Dosing tank ( p
aPercolation Test Result Performed by.. i�t�, i.:1.... `..: L _�i?��_ _W Date ........ _-5 ��'...k....
,.a Test Pit No., I________________minutes per inch Depth of Test Prt._____J Ps.h___ Depth to ground wat r.._._.___h&.1
LL, T t Pit No. 2 ------- ._..nunutes per inch Depth of Test Pit....... l6_�.__. Depth to ground water ..........
�a, �_......•. t, ...._.�5n._....._.; h ..----------
O Description of �oil_4 - �• ...Q._r..�_(o fi 1 � � Q � L � r Zla' �_. ��.2�.e�..t-f!_R .. 1a � �
-a-4--
UNature of Repairs or Alterations — Answer when applicable........................•_.._.__......._...___...__.___....._..................................
................ ---•----•------------------------------------------------------------•------------•----------•------------------------------------------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 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 he trd of health.
Si----------------------------------._rJ�-:1L
Application Approved By... _..
Date
Application Disapproved for the following reasons: .................................................................................................................
------------------------------•-----------Q-----•----._......-------.....-----......_._......------------.------•----------------•----------------5---....._.....-----.........-----------•--•.._.._._..._
Permit No ...... =._----.... Issued..------ ` t> --a ----.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifirate of Tout pita trr
THIS IS TO CE MYT,h� e IpAividual Sewage Disposal System constructed
by-• ..................................... ........ .. .........__....._-.r....---..........•--•---
) or Repaired ( )
at. �o`�.._7_._.>��C'1 �J t-.��.. ._ .G/'�'. ............... _.
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
",,,application for Disposal Works Construction Permit No .... __ Zm- 3___7. ,(�5___._... dated .... t-0=8792 ................ f Vly `
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCTI N SATISFACTORY. ...---------------•---•---• _.....
.DATE........ ...-----:.... ........... Inspector ........ -- -- ............................
--
4_.