HomeMy WebLinkAboutApp-Permit-ComplianceIn
No...25 .... Fizz .....1. . 00_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH C U
TOWN OF YARMOUTH
Annliratiun for Diunuuttl Works Tunutrudion Ventit
Application is hereby made for a Permit to Construct
System at
..................................
Location - Address
....t. l�,�l. __.. ... G1.✓..�4. �s..l�j ...............................
Owner
.._-_--_—
Installer
Type of Building
Dwelling -•= No
Other — Type
or Repair ( vran Individual Sewage Disposal
...ss�'...Y.e=sem.. .......
or Lot No.
�.... la4........ W.4 )l .........................
Address
-99...T1 q ............... =-................
Address
�.�✓ Size Lot ................•........... Sq. feet
of Bedrooms.......... �LsJD.......................Expansion Attic ( ) Garbage Grinder 4v)
of Building ... L4 No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------------------------------------------------•----.._...-----------
Design Flow ................... I ...................gallons per person per day. Total daily flow .............. o...................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........................
Description of Soil ..........................................
-------------------------------------------------------------------------------------------------------------------------------------------.--------....----------------------------------------.........
Nature of Repairs or Alterations - Answer when applicable..... 1.054 ...5454ctc'..-5-yl � .... .........
--'0 --- ,0.K ...... a........ .........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli
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 boart�of health.
11%.D t '/ I )
Application Approved By....
Application Disapproved for
PermitNo ....... ..,�---------------------- -----
�j Date
ate
te
Issued- .......... rv9Date Da......._
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH V
(9rr#ifiratr of Tuntnliattrr
THIS IS TO CERTIFY, That the Individual Sev&;�ge Disposalf�ystem constructed ( ) or Repaired (t '
by...........................__... •-••----------------------- ................. ...... ........... -
Inst ler
at................................................................ JQ,7._S�.I; ,a4 _� /Ez easl.---4,V-,------------ 6A_)_t.Y:............................•......................
has been installed in accordance with the provisions of TIT �5 of State Sanitary Code described in the
application for Disposal Works Construction Permit No.------ .-- `1_.._- ......... m... dated........ ., �THAT
._.._...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU AN THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............ '. �r.� G ;._..�............................................ Inspector