HomeMy WebLinkAboutApp-Permit-ComplianceNo._...!� -... Fu$......IL.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works TonStrudion 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair (&4 an Individual Sewage Disposal
System at:
Location - Address or Lot No.
..........................................................................................................................................
Owner Address
r/t9d ..................................................... ..•.-�..ajP ....0..uj..18.r11e.�'W..... ku..,..... Y..-..................
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms...............3.........................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures..-•...........................................................•------...-----....---------------.................•-----......------•----
Design Flow...............�Y.0.....................gallons per person per day. Total daily flow ............ 3. 0.................... gallons.
Septic Tank — Liquid' ca.pacity../gocl.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........................
Description of Soil ...................................
--------------------------------------------------------------•----•.......... _......_............-- •-•--•------------•------•-•-----------•---•--•-------•---------------------------------------------
Nature of Repairs or Alterations — Answer when applicable..../_ _...S-y.0z'Zo........ /-.O-ao.... s_7 .r----.
.... Q...._.a1?.x--------------------------------------------------------.------------------..........------
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 #ealth.
Application Approved By ....... t�
Application Disapproved for the
Permit
.... ..._.
Da
l Date
Issued. .... 1.�.-_1'5— Z--Date..--.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH ?jt
Tntifirat a of Tompltttnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by................................................... 3 .1,4a_._... ............... ............-•----................---•--••--•------ .....--•--.....
( installer
at............................................. �m ....U(s!'...A=N-CV'f4-.JILCI................ P.a.-...............................................................
has been installed in accordance with the provisions of TILE 5 of T e State Sanitary C de ap ri n, the
application for Disposal Works Construction Permit 1Vo.._..... _.�.t.................. dated ....... r......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS RANTEE THAT THE
SYSTEM7�1. FUNCTIONS SFACTORY.7
DATE................................. ..... ...........••........... Inspect .... .. - ................_