HomeMy WebLinkAboutApp-Permit-Compliance.�1..' ..j.�. Fzs,.�E,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion rumit
Application is hereby made for a Permit to Construct ( ) or Repair U�4 an Individual Sewage Disposal
System at:
w� i%'Q t off. �_t_oa.... rn�-�
Address
..........-- •^•-••--.....r........ _... ... -- or Lotljo, r....-jl� ....
................=---- --------' !: .......... r :l.......w..j.................... - .... �/..... ..............
-�'''`•7:LL� - -.- off• -^k......--- - -'•� Jddresg.�% .rte ........
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 ( )
Otherfixtures ..-•--•••--••.•--•...................•......_................_.....................-•-••-•-••...-•---•-•----.
Design Flow ................... ......................fgallons per person per day. Total daily flow .............. �` gallons.
Q
Septic Tank — Liquid capacity/A44L.gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Midth .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No .......... Z...... Diameter ...... f --G__..... Depth below inlet .......�..r ..... Total leaching arm..................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 Re airs or Alter ns — Answer when applicable....... 0I _lJQ.0.. jam...! !............ .` .
-70 ....... f�.j..... P i
Agreement: ...
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance th
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 issue Wthb rd alth._I si ........le- ......... ........... .......
Application Approved W. ..
Application Disapproved for the following
Permit
Date'
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifiratr of Toutphanrr
THIS IS TO CERTIFY, That thq Indivi ual Sewage Disposal System constructed ( ) or Repaired
by.........................................................................................................................................kj ......................................................
/� /,jC lSta& s
at...................................................................----�.....--------•--.....-----......----------. .....-•----•---------........---- v`'------'. ..............................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as de4cribed in the
application for Disposal Works Construction Permit No....... 3 ��.f'�... dated..........�� .............
THE ISSUANCE OF THIS CERTIFICATE. SHALL N BE CQNT,RUED A A A, T E AT THE
1
SYSTEM WILF NCTi ` SATISFACTORY.
DATE................... .......................... Inspector....... ......................- -• - .....-•---.............