HomeMy WebLinkAboutApp-Permit-ComplianceNo .. .[.... Fss_... �5...�...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH r
TOWN OF YARMOUTH
Appl ration for Disposal Works Tonotrudion 1rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (G) an Individual Sewage. Disposal
System at:
... :....:Tt:Qre� .:l3:can k..lin sd..................................... ....... .°A- -- •-- . (_J7 . -v . 7.... ..... .............. .-..............
Location . Address or Lot No.
................ _..»-...--.............. .-...................................................... ........••..••.......--•------...............----.................................._....»........
Owner Address
a -s ............................................... t � 3n r n�au�.6 ox .; M,a.--off � ...-------.:...
Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms ................ 11 ........................ Expansion Attic ( ) Garbage Grinder
ok Other — Type of Building No. of persons . --.......3 ............... Showers ( ) — Cafeteria ( )
dOther fixtures ...................:• ---•------•-•----••---•--
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity-14_AF_...gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
3 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 ........................
W Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x
0 Description of Soil ............................................................................... ---•-•-----------...----•--•--------•---•-•---•--••-•------.............................
W
U ,------------ * ............... * ...... *'***-,* ------------------------
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W-••-••-----•.................................................•-...........-•-----•--•••......•••...---.....---•------............ ---•-----•---------•----••--......................................
VNature of Repairs or Alterations—,Answer when applicable ..... G�.4�.'>'��-......`ei��.4.!�.`..�.....1t.c1..S �%"'��
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLij 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ued by the boar of hea
Signed. r r .��f ............... t 1... �
Application Approved By. .......... . ... ................. .........1. -:.y. _..-
Date
Application Disapproved for the following reasons: .................. ----•--••.....•--•.........................•....._...._.....------•--•--...•----._.........
.............................................---•----•-••---.....-----•---••------------•-----••---•----•.-•-•---••--••---------•----..............._....-•--•--•-••--....._..---....•---..............--
C� _Date
Permit No..../..J�.-..: ........................ Issued.............- .:1...... ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS—
BOARD OF HEALTH
#: TOWN of YARMOUTH
Trrtif trate of f omplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed ( ) or Repaired (�
by--••-•••-= ....................... C"L.s-...c_u sl tr>d�..2 �c .:.......Psv...Qm�..,-......YArz �zki fx��:,..C��a...........................................
Installer v
at..................................1.... hQr.3ui ew.... ronk....i 4., ....... W.e !kf --....... - ...-
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code asdesc 'bed in the
application for Disposal Works Construction Permit No. 6314-:7/9-1 .............. dated.--..... ..............
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. '
DATE...............C..:.`...................................--- Inspector.. / _. '�/G���.. _..-�%�......