HomeMy WebLinkAboutApp-Permit-ComplianceNo. �L._^. g.I
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fis.��_' O'C�
1
Appliration for Disposal Warks Tonsirurtinn F//rind#
Application is hereby made for a Permit to Construct ( ) or Repair � an Indii idual Sewage Disposal
System at •
Location - Address i� or Lot No.
._..................................................5-� ..
Owner Address
� �1...............
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 ( )
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 ........................
Description of Soil............
------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------••-••--•-----
Nature of Repairs or Alterations —Answer when applicable ..l0!0 ___................................................
... ...................... --.................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT11 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been Code
bel �,th
Application Approved By.......�9,1� '� ...
Application Disapproved for the following reasons:
-•----...�.... ate ---a--���
Date
.................•--.....----•-------....---------•----...........--------•-----------------.......-----•...------------------......---------------------------.........------------......--------------
Permit No ..... 2'....../.q/
' ......q /--------------•-........... Issued ......... ` - a-�-6�-----M D.. ......
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irrfifirate of Toutplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer -
at ......` r_ -2...r 1- .
has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._`� _..1 -VI ----------- -... dated ___...a _.-1L_P_. = YS--_----_------.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE........... - `�?.. .......•... . ._ Inspector = -- / -... ���=--�!. .......