HomeMy WebLinkAboutApp-Permit-ComplianceI L,T ern,
No----------- ----------- I 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F>xs..f ..
TOWN OF YARMOUTH VIA P 4 ®����
Tonstrurtion rruti
Application is hereby made for a Permit to Construct ( ) or Repair (i,-j an Individual Sewage Disposal
System at: 8
. 3 ry- 6W i eA1 jA.J o •-• - - ..._.. - • ...... 1�`'` - `� ---- � -` ......... A ...................
.............. __.- ---- •---- -- - -
tton - Address or I o o.
��.
._ .... - ... _.........-- -.�- b�
�--_---_.Owner L/ � --_.-_Address
.... ......------.....--- -------------------.---------.------------------------ ` is �4----------------....---.....------.............
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms.__ Z--______________________________Expansion Attic ( ) Garbage Grinder
Other —Type of Building ................... ...... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------- - _ ----- ---••--•-••--•----•---•---------..-•-----•----------------------•----•-----••......-------•-----•---••-•----•----•----•....---•-•
Design Flow ...................................... ....gallo per person per day. Total dai o........................................... gallons.
Septic Tank — Liquid capacit ........ ... ga ns Length ................ ...............Depth ................No ... tal 1 ching area .................... sq. ft.
Seepage Pit No .................... Diame er........._.__..... Depth below in t_............. --- Total le ching area -----___----_--.--sq. ft.
Other Distribution box ( Do ' g tan ( )
Percolation Test Results Pe or ed--------------•---...................... ----•-•--•--•.. -•--•-• D te ........................................
Test Pit No. I ...............: ut s per i ch Depth Test Pit .... ............... epth to ound water ........................
Test Pit N \il
-----------minu s per i ch Depth o Test Pit ...... ............. o ground water ........................
Description of S................. .
Appliration for Disposal Works
......... -•---.------ ••--------- v^------•-- ---------------------------- --- -
Nature of Repairs or Al ratio — Answer n applicable,��fli �l_ ...d'-�
---•-----------------••--••••--- •-- G...
. -
Agreement :
The undersigned agrees W install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1 � 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 b boar f health. C
Signe Vl.•�---
Application Approved By ..... .......................................... ---•-•--............................ ----�----•"-" t�C �---
Date
Application Disapproved for the following reasons:.--------------•-----------------------•----•--•--------------------------------------------
.........................•---------------------------------------------------------..............-........-----------------•-------------•------•--..................................
-
Permit No...: S. ... -- • Issued ........... �-- ate ..........
Permit
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(irrtifiratr of Tontphaurr
THIS IS TOP&JTIFY, T thgAndividual Sewage Disposal System constructed ( ) or Repaired
bY...........................
% �Jv ......--.r......----•----•-•---•-----•-------------------------------•----------------...---------------------........-----------...--
,! /� Insta11
atC.T ZQ /V �.''!!'............s._.. G. ��-----._ . ..-------------•-------------........------------------...........-----...
has been installed in accordance with t e provisions of IT TIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ..... ............. dated-... tI_...........-_`t?,�..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................•-----•--•--------------•--•------•------ Inspector