HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fss l s--
Appliration for Disposal Works Tonstrurtiun ' 1hruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
�i✓�� � ZC)T C- MOP -Go ............................
........... � `.._...1:...-- -- - l- - -=------------ - - - •- ' -- ---•--
--- - --- -------
�� c ti �a ress or Lot�Nv
.....---�!� r- -� � - I�'_`'_ .._ p,L.. .Q. S. .1- - ......... -- � -� ' .....tf.WSJ...I..-•----•................................
�} . -• p Address
caner
�.......................�..---------------------•-•........--....----------.......-----...-•--------•-----.............------............
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. 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 ........................
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Descriptionof Soil ..........................................................................................
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• -•-•---•-----•-•--•...........-•----
Nature of Repairs or Alterations - Aiiswer when ytpplicabl) ...
.................................
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
Si a b
operation until a Certificate of Compliancehasbeen issued bye ��- d of health.
.......................................... ------------------------ .......a
Dat
Application Approved By. .---•-•••.............................................................. ....
S ` E% Z,
Date
Application Disapproved for the fol wing easons:••-•.........................•-••-•------•----._.........--•--•--................---•••......--••-•••...........
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Date
Permit No........ 9 Z _±�� -�-•--•------.. Issued.......
- ...........--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(9rdifirai r of Tautplinurr
THIS IS TO CERTThat the I iv' al Sewage Disposal System constructed ( ) or Repaired
by.............................................l.. .._��...�.�... ("2D.......................................................................... ....I ..........................
Installer
at--... f_` �., .... L_011 ..... .el;�.................. - �.it a .........................................
has been installed in accoance with the provisions of TI 5 f tate Sanitary Cod . s de - ed in the
application for Disposal Works Construction Permit No --- ,�'^ dated---.-- _..
,-.
J
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRVDSAG AR NTEE THAT THE
SYSTEM WIL FUNCTION TISFACTORY (y `DATE....:- .•. ... Inspector • .. ... - t`--- + ................