HomeMy WebLinkAboutApp-Permit-Compliancet U x5L-U� 11-Qkl� VI —A.)
No. . ............ Ficis
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for 14sposal Varks Tons trurtion'11truat
Application is hereby11�t (
,,made for a Permit to Constr or Repair (1,�an Individual Sewage Disposal
System at: /-,It>
IqAP-gol
................................... ....
4�
r I: 4V
Z5 1�fi Address
...............
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
Other fixtures ...........................................
--------------- * -------------------------------- *"* ...... * -------------------- * ---------------
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.
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........._.._...._._....
.................................................................................................... .........................................................
0 Description of Soil ........................................................................................................................................................................
--------------------------------- " ---------------------- " ------ " --------------------------------------- " --------------------------------------------------------- " ------- ------------------------------- .. ....................................................................... ... ---------
Nature of Repairs or Alterations —Answer 7
er when applicable—d�.?/12 ...... 7; 411
, - --- --------- ... ......... ... �411 - ----- /'.
N'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 atertificate of Compliance has been issued by the board of health.
ij led.
S ........................................................ . ......................
Dge
-- - ---- - -------- --- ..........
Application Approved j3y..-, -.- . ........ .................................................................. 7::� ............
Date
Application Disapproved By
othe lowing reasons: .................. ............................................................................................ .
............................................................................................................. 4 ........................................... ......... 2 .................................
9k— ko PS 15( 1 --
Date
---------------
Permit No-----------------.. ..................... Issued..-----_.....- .......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
THIS IS TO CERTIFY, That the Indivi&4S-ewap Disposal System 'constructed or Repaired (V)
by........... ....... ..............................................................................................................
Installer '5
at ......... .......
... ........ .. . .. .... W .. . ..... ...............................
has been installed in accordance with the provisions of TIT 5 of The St San . itary Co(�t-as- 4tcrit in the
-------------- dated...:._.... ...... .. ........
application- for Disposal Works Construction Permit No. .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NdT B, UCCO�T�NSTRU�ED AS A GUARANTEE THAT THE
SYSTEM WILL- JFUOCTI N
IATISFACTOR.Y
DATE:.... ..... ............. .................. Inspector ...--•------•-••.........' ...............