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App-Permit-Compliance
Fm$......1.5......_......_ THE COMMONWE LTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF YARMOUTH i Appliration for Disposal Works Tonstrnrtion Pyrinit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....K 11 .: _..... s.e ---... .&------..... i<} l au .....---------------�-.•-- Location - Address or Lot No. ................ ........................--•--' .................... ......-•-ti•••---••--....------•--------...-----•---....------------............................ wner / 1 �1 ,+q % A mss /� �.._. t n� 3 l0 3 C/. �y�. _. ��4 / �5 ...... C�.C� ---•--. --•-•- ------•---•-.....------•----•-----•-- Installer j, ie Address Type of BuildingSize Lot ............................ Sq. fee Dwelling — No. of Bedrooms --- �_.-�_ .�'. *. a )........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/ a _.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 ........................ ----------•-• ..................... ............................................................. ......................................................... Descriptionof Soil ........... y` �--------------------------------------------------------------------------------------------------------------------------- -----.----- ..............••------•-----••--• •-•-•-•--•-•••--••-----•--•----•--....._._....................•-•---•-------•----••-•---•--•--•-••---•---------.....-•-..._.....• • •----..........•----••---------------- --------------------••--•----------•--•------•---•-------•--------•-----...................................................jj/ - Nature of Re rs or A ter ns — Answer when licable._.___ti1_6'l1_......_.__1.._...5._ _._ ----•-.'----....-•---•------. �` ----------------------- Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary e — The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n iss ed by the b d health.OL _ �Signed....-_-... ----------•-•-••---• - .... te Application Approved BY ---- ....... ----- f ...... Date Application Disapproved for the following reasons:---•-•-------------•------------•---------•------------•------•-----------------•---•--•••------......------.. .--------------------------------------------------------------------------------------------------•-••------------------••--••...-------------•--.............................. 1 ` Date PermitNo.... !L-1 ............................................. Issued ------------------------------------- -------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH (9rdifiratr of T-amplittnrr THIS IS,30 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Kepairea- (xj by--------.,,7 .............. Z".1. I.& ................................................................................................................................................ /j Installer / at ...... �j �� © Jam`' i +PGti....../._� tl . '7. k... --•-••------------------•--.....-------------•-- has been installed in accordance with the provisions of TITLE of The State Sanitary Code as described in the application for Disposal Works Construction Permit No ... �4' S�: ......... dated___.--.),- :.!!�.S.. ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTI,ON SATISFACTORY. DATE................. �. �?� �......................................... Inspector.....' .........................................