HomeMy WebLinkAboutApp-Permit-ComplianceNo.._1..�1____�.... Fms......�s
THE COMMONWEALTH OF MASSACHUSETTS 0 a
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal Works Tonstrurtiun jhrmi#
Application is hereby made for a Permit to Construct V -51 -or Repair ( ) an Individual Sewage Disposal
System at:
............s:/J... - - --
----------------.:
cocati Address or Lot No.
-- . .. _......... Q..----- U ............................................ --------------------- ----------------- .....--------------------.....----------------
Q -Owner T dress
a ....�-'_........�z�:�...... ............................. `�'�T'`1.�� .....� _n............._
.. .... _... ..............................
Installer Address
Type of Building -3 Size Lot............................Sq. feet
U Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building No. of persons ............................ Showers — Cafeteria
04 Other fix ures.......................................................
W Design Flow ......... ............................gallons per person per day. Total daily flow ...... 0__:�i.......................... gallons.
WSeptic Tank — Liquid capacity.lO(J.�.gallons Length_.A��_!.. Width...�!.k... Diameter ................ Depth..-_._
x Disposal Trench — No. ........ Width --- ZO---------- Total Length .... 9A_� --••---- Total leaching area_._--J�-••---.v -�
Seepage Pit No ..................... Diameter..................:, Depth below inlet .................... Total leaching area .................. sq. ft.
Z 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 ........................
----------------------------------- --------------- * ------------------------- *" ----------- -------------- " .................-•-•--------
Descriptionof Soil ........................................................................................................................................................................
W.....................••---------------•-•--•----•------•--•----------•-----•----•-•-•--•-••---•-•--- ...-•-•- •-- -f -------.....--- ................. �F
Nature of Repairs or Alter tions — Answer hen applicable_�../�.. �. . .._.....���U __ ����_.........�........�.._........
-------=---------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 e board of health.
Application Approved By ........... • `il'�--------------..........
Date
Application Disapproved for, e f ollowi g reasons:---•---•------•-••--•------•-•--•-----••------•---------------•---------------..........._...---•--._.....__.._
.............. ..................................................................................................... -•----•-------•--------• •-••--••......._._.....---..............----•--• •-•--•-•------
y� Date
Permit No .......... 151,.:7--------------------------- Issued ------------ ..................
Date
TTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH /1/" 1 �""I'q
TOWN of YARMOUTH
(9rdifirate of Tuntphaurr -
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed K_)" or Repaired ( )
by----�-:� �XC eu.✓3.c_ ------------------------ ------------------------_____-___-----------______......_---•-------________-____--•----..._______-_-
__
t� Installer ,1
at_...- ./ .._....._%'!/ [. ....... -------------� =--.. a�j3Nr�L2u;Y------._ !!_..... ---- ._._....... ........
been installed in accordance with the provision's of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..___ _✓ .. .�................ dated.........L=_. :_J `�:_.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -�
DATE............ - ............................... Inspector ----• -•-r