HomeMy WebLinkAboutApp-Permit-Compliance"4_f V YARMOUTH HEALTH DEPT.
No ..... .................... 1146 ROUTE 28 FJCIi......./.'
THE COMMO§&l&WM.of,..MAF&8y6JeVTTS
BOARD OF HEALTH
.......... MW..Vt................ OF...�.y.&rft10.4A.......----------------------------------------------------
V
Appliration for Disposal 19orks Tonstrnr#'tun jhrmit
Application is hereby made for a Permit to Construct
System at:
...1 ``�.^-...10gr.!(� ee Road _ c�tclrA #v94YA._...
... . _....•----•` - ocat�on - Address
r------ 1- ... r----------------------------------•-------
-e
_Ais... w.--•-•............. - Own ..----•--••-•-----------.....--•--------••---
Installer
Type of Building
Dwelling —No. of Bedrooms
) or Repair E*) an Individual Sewage Disposal
..................... L01.....I...t io p = - --
No
L.�i LI.C.!i<`P.IFl4..............
dre
�$� GIIY�_ Sir ASh�SF Address - C r -----------------•--•---------
67
Size Lot ............................Sq. feet
.................... 3...... 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 capacity ............ 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......................•-----....................--------..........-------------•---------------------•-----•---------------------.... .............
•----------------------------------•---•---------------------------•-----------------------------•-------•---•---•--_.. _..._
Na ure f airs or Alter tions —Answer when applicable.__.�_f f_ �11i�.�..
Fs ,�:..w a- --,t. rr% !--------------------------- ::.....:.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT11, 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 boaprdf health.
d.C��� ! "
Dat
Application Approved By -..-•-- ---
Signed..
Date
Application Disapproved for the f ollowi reasons--------------------------•----•-----...------.._.._..--------------------------•-----------.....-----------•----
.................•--........................--------^--••-•-•-------......-------•-•-•-----•-------•---•------------------------•--•----•-----•--.................................
.Date
Permit No ...... ........... . ....... .... Issued- ............. .�.. ._.........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH:
...........h2S ?.n.................. OF..... 'i9 �;t�?P(.c; 4......................................................
(9rdifirttfr of Tomptittnrr
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�
rl..� +,
b // rr..tx. , , -.-•------------------•---•-•--------------------.._._.
/� I r Installer
at- /'•t-1?.•=- - ----------- t
has been installed in accordance with the provisions of TTTL 5 of T e State Sanitary Code as Oees ribed in the
application -for Disposal Works Construction Permit No ..... dated _. �_`�
--•---..... j -------------•--.....
THE ISSUAN E OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A/ C:U�ARANTEE THAT THE
SYSTEM WILL FUNCT ON SATISFACTORY.
DATE............. ��-`--....................................... Inspector...4, :1, :.....
i