HomeMy WebLinkAboutApp-Permit-ComplianceNo-_ 1-__ 20-7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Application for 11iupuudi Murky Tontrurtion 1hrutit
Application is hereby made for a Permit to Construct (✓�r Repair ( ) an Individual Sewage Disposal
System at: --- .......ALZ�.- -.1..............`�.-. _.. .�W. ... _ l � ......- -- ------
�1--Locatatiion - Address ..............
------- or Lot No.
--
%f �p Owner Address
�i?:.�I..........eGlr-----------------------------
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms ............ ,_............................ Expansion Attic (wq Garbage Grinder (4e)
Other — Type of Building ..RR- �=__R_____ No. of persons ............................ Showers ( ) — Cafeteria (ram
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. 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
-----------------------------•---------•-----------------•-----------------------------------...--•------------------------------------.......-----....----..................._..
Nature of Repairs or Alterations —Answer when applicable.._..._.cl..:? .............;.i.rZT .......
•------------------------- ---------------------- ---------------------------------------------------- ----------------------------------------------------------------------------------------------------
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 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 health.
Sig . ed---- `- Fr'------•----..-----
�s� .L ../
�t
ApplicationApproved By..__. _.. ---- ------------ -------------------------•----------•------- ------ J�........_. .......
Date
Application Disapproved for the following reasons _..--- ------•-------•---------------------•----........----------------•-•--•---•----------------------•------
Permit No ........... -
Date
Issued .........
...- - �_ . .................. _
Date
��- -P-�ov THE COMMONWEALTH OF MASSACHUSETTS I v
BOARD OF HEALTH A�
TOWN of YARMOUTH
(IntifiraU of font rlittnr�e
THa IS TO CERTI Y, That the Individual Sewage Disposal System constructed ( ) or Repaired (K)
H,I ..... .
—� _
at ........... 9.... rJ t........... -1-�- � . �nstaller
� ...
---------------------------------------------------------------
has been installed in accordance with the provisions of TIT of The State Sanitary Code as describpA in the
application for Disposal Works Construction Permit No.__--_--L_Q. 7Q dated._-:._�"'.�"'_.. _�......_...
. fn
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
0.10eX2
DATE.. g .�1.=�................................................. Inspector..-: