HomeMy WebLinkAboutApp-Permit-Compliance- f �.�
No.... � �.. Z.!� .......J....
THE COMMONWEALTH OF MASSACHUSETTS
ft
BOARD OF HEALTH
TOWN OF YARMOUTH
11�
Applirtt#ion for Disposal Works Tonstrur#iun Hemi# G
' Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
'
stem at _. --------- - --- � "' - - -- ----_. _... .- --- ..--.... 6I.._..........
Location - A ress or t No.
................ _--....__....... _....-----------........•---------•---•-----•---------.... � :_Ec ?r � ._ .....---1, - --•-------.........
Owner Address
j ...�? .----.--- -•-----------------------------
._...Q:.......
Installer Address
Type of Building Size Lot ............................S feet
aDwelling —No. of Bedrooms ............. -------------......------Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtur s ... -••---------------•-••--...........-••-••--------.---...-••---•....._..-----•-----------•--•----•-•--•.._...-•----------•------•---•.......••----
W Design Flow .................... _r_ .......... gallons per person per day. Total daily flow ................................. --......... gallons.
WSeptic Tank— Liquid' capacity gallons Length ................ Width ................ Diameter................ Depth ................
x Disposal Trench—No.... ................. Width.................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
14 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ............... .........
-----------------------•----------------....--•---.......------........--•-•.....--•.......----
Descriptionof Soil ..........................................................................................................
.7..................................................................................a......................................................
---------------------------------------•-•----•---...---------------•-----------•-----------------------•--..,..---•-------------------- -------
Nature of Repairs or Alterations —Answer when applicable_______________ ______. N4,1.�(ct ��...,�11fJ--y,�-_____•-•.
-------------------------------•----..........•-----•-------•-.....••. .T---------------------------.------•--------------------------------------------.•----.-.-----.----------------------•------.
F 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 ulidersi ned further agrees not to place the system in
31 operation until a Certificate of Compliance has ssued y the boa d of health.
Signed-- -•--• --- -------------••--••-.---- t �. ...
�^ ^�Dalpl
L Application Approved BY---... ..................... •.......
Date
Application Disapproved for the following reasons: ................................................................................................................
.....................................•------•---•-------......----•-•----------•--------....-----...-•---.--...---...........----....---......---------..................Q-•--.•---7-------....----•-•----•.
Permit No........ � .. ........... Issued...... 17 6 [..
Date
' e -------------..........
Date
THE COMMONWEALTH OFA MASSACHU.,SE*-l`S ,
BOARD OF HEALTH
TOWN of. YARMOUTH
Tatifiratr of Tomplittnrr
THIS IS—TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by.................. ...... .r��..-••-----...---........ .... -- .--•------•--------....-------------------- ....../........-------- ...---•--------....
Installer
at ............. . 6x-1.... ` �i�Ct- ' Lu � -'� Lt/:C ...-------------- ?�AFI ...... `---.............------
has been installed in accordance with the provisions of TI;V. of.,The State Sanode as des rd in the
application for Disposal Works Construction Permit No.__. _ -n-1-111K ... ted__ tTEE
- - ----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL N T BSE- CONS UED A THAT THE
SYSTEM JILUNC O�V SATISFACTORY.
�.`DATE...�..... ...._..--- Inspector -- --.....-•.......................................•---......