HomeMy WebLinkAboutApp-Permit-ComplianceNo..../_ .!Q.. Fns ............._./..._
THE COMMONWEALTH OF MASSACHUSETTS �rg1�r
BOARD OF HEALTHC`�
TOWN OF YARMOUTH
Appliratinn for Disposal Works Tonstrnrtinn jrrnti# :a
Application is hereby made for a Permit to Construct
System at
.......... Q._.t-.......1..---- ! •---42-�..:............ .• -....
`3e AC ` { - Location •Address
1.
--...��....__ L....._ ---,J., ..._..........
1.._.....�..................................................
Installer
Type of Building
Dwelling — No
Other — Type
) or Repair Q,,j"'an Individual Sewage Disposal
-
.............•------------------- -1�-- ................. ................
- or Lot No
.........................................
Address
Address
Size Lot ............................ Sq. feet
. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----•------------------------------------------------•----...----------------•----.•.---------....---•---------..__....................--------------
Design Flow............................................gallons per person per day. Total daily flow ............................. ............... gallons.
Septic Tank — Liquid' capacity___..__.____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_____________c_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
--------------------------------------------•---••---------------••-------------••------•------•-----•---------------e /
Nature of Repairs or Alterations -Answer when applicable__'e...
l__/ -'b n/ -ow__--- -.-2- ------- --------------------•- ...••
Ir --- e_!`---_____--------------------- - --------------------- _-------------- --------------
Agreement:
_---------___Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi+: 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
he boa of health. j�
.......
Z11
Application Approved By --- .. 7greasons:
-------- ___1��G %�� ��..
--------------•- ----- D..� .....
Date
Application Disapproved for e f ollowi --------------------------------------•--•----•----------•-•-•-•--...---•------••-------------•----------------
•----------------------------•---------------------.......-•-------------•---------------•----------------------------------•-------------------------------------------J�-----•--•
Permit No.._..._....
D1/• -•Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifirtttv of fanntphttnrr
THIS IS TO CFR'T-;FY, That tj;e Ividual Sewage Disposal System constructed ( ) or Repaired {(
by............................... �< <- -----•-n i ...................................... ...----........--------._...._....._.......-•--- ....................:.
- nsSall r -
a� !.----------._.....�._ cv:..
has been installed in accordance with the provisions of TITLE of Uoz State Sanitary Code as described in he
application for Disposal Works Construction Permit No..___.._. __ ___._... dated --------- ice_:._-?__`.�.___._1.�....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED, S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
f i ice /
DATE ................ � ....... Inspector_..����'��._� -