HomeMy WebLinkAboutApp-Permit-ComplianceNo. (7a -3 78 FzS.....1. _.. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
, ppItration for Disposal Works TonsIr .r#ion Tirrmit
Application is hereby made for a Permit to Construct ( ) or Repair (K an Individual Sewage Disposal
System
at:
�10e&'5 '4 . L11:4... °. ` !9 !....... �:`.'. `- ... �1....... -. `�� �. ........................ ......
Location Address or Lot No.
-----�� �.D__. G:. ti/.e. .l. .- ............................•----... ....�'�I'/Ll ......................................•--......................
Owner -•• Ad r s
a �AG(°E...�.. ... ........ ...............................
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 ( )
04 Other fixtures .......-•--------•-•----•.......................................
Design Flow ..............,? .......................gallons per person per day. Total daily flow ........zZ-.-.................... gallons.
W Septic Tank — Liquid ca.pacity/69fl..gallons Length.- ...�. u. Width. _!... Diameter ................ Depth ...4........
x Disposal Trench — No. ..... /............ Width ..... ........... Total Length..... CI....... Total leaching area...
Seepage Pit No .... .�......... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box (9G) Dosing tank ( )
~' Percolation Test Results Performed by ........................ .........__........_.... Date ........................................
1.4
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water........................
0:4 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
P4.................. .................................................................................. .........................................................
0 Description of Soil..................................................................................................•----....................---•--................_...--•--•----•---.....
---------------------------------------------------------•---........---•-----------...---.........----.........................-----....--•---•--............................................_.........
Nat re of Repairs or Alterations —Answer when app -cable..../ �.% triGL:......%D D•• 6 -•---$ ..7'_,_.-- 'PI.6
�......................................... ...........
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 b en issued by the board of h alth,
�r�F..'.F C q
Signed. ... ................. ��? .f ....
Application Approved By.... l a ��
Date
Application Disapproved for othefoUo ing r asons:......................•-•--•--•••--•••-•.....•--....---...••-•--........-•-•--••--•-....._..........---.........
ate
Permit No.... .. .?7 ..
....-- -_... ssue.......... -. ---------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Ur if iratr of Tompitaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or
bC/� G L G......................................•................................................................
Insta11
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as i
application for Disposal Works Construction Permit No._ y a....8 dated.._. . o�q1.
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CO TRUED A GUA
SYSTEM WILL F NCTION SATISFACTORY.
LO/ DATE...........�. �� .. g ............................................. Inspector •--....--------•-•----...... .............
Repaired `A-
in the
! � ...............
THAT THE