HomeMy WebLinkAboutApp-Permit-ComplianceNo -211-165,
o... 211.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
S
4-"1 TOWN OF YARMOUTH
Appliration for Disposal Works Tontrurtion Frani# k
Application is hereby made for a Permit to Construct ( ) or Repair (wl an Individual Sewage Disposal
System at:
...........r.r�.-a .........................
Owner
--------_�_..._o...... ...---------------------------•----•--.......
Installer
Type of Building
Dwelling — No
Other — Type
Other
M1W rad
----.-.-•- - ._ ------ -------•--- �s.._.....-----.-
or LQ4NO.
-. _Address
Address
Size Lot ............................ Sq. feet
. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
fixtures------------------------------------------------------.----•...-----•--•---...--------------•-•.._..._...--•...--•--.._....-••---..__._._........--_..
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ca.pacity......_.____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. 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....................•-----..........---------------•------------•-----------------------------------•-__•••-
......-•---------------------------•-------..__...-----•-•----•------•----------
Na�of Repairs or Alterations - Answerer
Agreement :
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 issu the b and of health.
Signe-- ll ------- -•---........................................ -1 ..................... rT
2eQ
Application Approved By ................... .__.........
Date
Application Disapproved for the lowing reasons------------------•---------___-•-----------------------•------•-------------•---•------••---•---------•--------
...........................................•--------...._....-----•---......-----•-----......--------......-----•-----------------•----....--•---------•-----•-----------•--•-------•--•..........
q D to
PermitNo ........ 11 ....... ------------------ Issued- ............. ............ ........
Date
-------------------------------------------------____ .___ �..—_----
THE COMMONWEALTH OF MASSACHUSETTS !'�-� A
BOARD OF HEALTH
TOWN of YARMOUTH
Cnrdifiratr of Tout plutttrr
� ft
� -� �•� c. ,� , ,� ter. • �`�'"
THIS IS TO CWIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by------------------------------.��'.�: �.�.�---...-------------- •---------•-------------............---•--------------------•------•---------- ...........__----.._
Insta11
S� ......... y't-rc"n-• ------------------------------•--•-•-•--......•-----._.....--------•----------......_.....----
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_5_6... dated ...... _`_. .. ;r ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED A GUARA i EE THAT THE
SYSTEMA WILL FUNCTION ATISFACTORY.
DATE.............••---�=- a� 1 -/ ---- Inspector---- y i-------- ----- --