HomeMy WebLinkAboutApp-Permit-ComplianceN0.2 Es Fns.j j _'.0 p.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Diupuuttl Works Tonitrurtion rumit
Application is hereby made for a Permit to Construct ( ) or Repair (t,,*f an Individual Sewage Disposal
System at:
30
-.'. %% Location - Address or Lot
.... &. aj&-d (2m..j� ...--•--------------•--•-------- •-..._... �'_. t ��ccqq 4i w�=L- t:..
..! Owner 0 Addr
Installer Addr
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms ................ ...oL................... Expansion Attic ( ) Garbage Grinder ' T
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.--------.............................................................................. .............................................................
Design Flow .............. 1.f_Q.................... gallons per person per day. Total daily flow .............. ?_6........._..........gallons.
Septic Tank —Liquid* ca.pacity../ aCgallons 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........................
Descriptionof Soil ------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------------------........................................................
Nature of Repairs or Alterations - Answer when applicable ___..A;E,.Ji,.--SC�.�... &_y- -Z,4 �...._..,C_a-P Q--------
Agreement: V
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 board of health.
., t .
Application Approved
Application Disapproved for
by
Signed.
following reasons: ............
Permit No._._.`.�`5------
----------- -----
31...E
�i _. �..
Date
/._..... `+..........
Date
Issued...... .....----- .....`•-•iJ......................
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Y._ /1M1 e.
Trriifiratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual SeVzge Disposal System constructed ( ) or Repaired ( t, )-
at ..........4 -ca.._ _ :-•J'--------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Codg as described in the
application for Disposal Works Construction Permit No.S__ �._`_ dated.--.-_�._/�f_5.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUN TION SATISFACTORY.
DATE................ �� .. �;:.. Z ? ...... .................................... Inspector......_