HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Disposal Works C>zuat��ritr#iun �(ernti#
Application is hereby made for a Permit to Construct ( ) or Repair (,-\) an Individual Sewage Disposal
System at:
-••-.-.--.-• L ion - Address or Lot N
�'� N----•— �- � . . ..... .. .... -- ° �i �,.t!- 3 Q- }........................... ........
Own
e Add
--------------- ............
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 ( )
Otherfixtures --------------------•--------....•............------......-•-----•-•---------••---..•-•--
Design Flow _.......5 .Z. ----------•--------•--gallons per person er day. Total daily flow ..... _mac. _-�Z----�..•...................gallons.
Septic Tank I— Liquid' ca.pa ity4_01D.gallons Length_ ---------- Width. -,'5 --------• Diameter ................ Depth ................
Disposal Trench — N SL Width_._:F�_._.-------- Total Length..c ...... Total leaching area....................sq. ft.
Seepage Pit No .... I .............. Diameter ... las ......... Depth below inlet__/r..�......... Total leaching area .................. sq. ft.
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 ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Description of S
.....................................
Nature of Repairs or
...._...00- _zivze --------•
...................
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 h sued by he boa It
Signe �+ � s ' `
--- --- Date.......
Application Approved By.... -•. .......... ............ .............................................................. .o' ��l
---••---------- - -----------•--•
Date
Application Disapproved f r the fol wing easons:-----•-------••-••-•----•-••-------•......................••-...---•----•-•-•--•-•----........................_
.....�� �Z_ Dau
................Permit No.---•--•---�.2-"2��....-------....__._...---�-------------...-----Issued:....�� ... ......_..._......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trx#ifiratr of Iffoutplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (L.<
by- ..................................... C.a_ P1LJ .Jn.V. _ i. 0111C .............•----------...................•..........................-----..........---.........
Installer
at............................. ;...5 ....... �5.5.+,� Nh Ak:.......5---------------------- a f � � �cSao T�'r-------------------------------------- ------------------
has been installed in accordance with the provisions of TITLE 5 of T e tate Sanitary Code a�j sc ed in the
a licati d for Disposal Works Construction Permit o ------ :o__ .�_7 dated__... .._ ...j
P t .4� y G...
PP P T...........
,T E ISSUANCE OF THIS CERTIFICATE SHALL NOFX-RE CONSTRUED_AS A GUARANTEE_ THAT, THE
SYSTEIoA 1lVILL FuNr-T10N,SATi FACTORY, Al)
r v
DATE...
,. ......... ....... ...•.rte Inspecto3- r
_, .,, u .