HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appltratiun for Disposal Works Tonsirartiun 1hruti#
Application is hereby made for a Permit to Construct ( ) or Repair (;OS an Individual Sewage Disposal
System at
qn VcaR r - tJ �S i du N 2r Low -Ez rn
....:.......___..__----- -=-= = ---- _ .. - .. ...... -- - r.. "_.......__------------. ----......... -_______
Location - Address ---- or • Lot No.
f '!4'... S t'r - 2-------•-- ------ -.................. ........................ ,.--- -
Owner
.... ...--�,..'. C.cl. Address
.................................................... 3t...................
Installer Addss
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............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ca.pacity___...._....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. I................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 ............................................................................................
.........................................................................................................................................................................................................
----------------•-----------•-•----•--• ...--------------•-.._ _._... --I -_.7�------- Nature of Repairs or 41te tions Answer when pplicab e_ ._._:_____�'6 �_...! « �4a �
0,31
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.% 5 of the State Saint de — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has een jA
yed by\the boar health.
Application Approved By...... 61.
Application Disapproved for the
rr� c
Signed ......
~ �4 1 ' e d
.. : . .. .. . . .. 7.... Date ....
Date
.....................................•--------q
------•---------------Q--�----j-----------...-------._._.......---._...........-----------------------------........... ---------••-----•...-------••-•••-
Permit No..........q..._5:..�.1._________... Issued_ ----------
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifiratr of Tuntplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (jo4
by...... f ::!: ..... i_! -1;2..........................................•---------=-----•--------._...........--•----------------.................._...---------........_......._
Installer
at ..... 9d .N_I�?.�tS-2Y�►.o..v_Tl.4.2dr2. .......................................................
has been installed in accordance with the provisions of TIT of The-State
toe Sanitary de d scri d in the
application for Disposal Works Construction Permit No ...... :�.'"._. dated .... ""____�_ Z._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NO!,"
CONSTRUE S A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............7_ Z 5' ... �............... ............ Inspector_.. .....