HomeMy WebLinkAboutApp-Permit-ComplianceNo.... ... Fs$...... �
THE COMMONWEALTH OF MASSACHUSETTS �nFr
BOARD OF HEALTH ID
TOWN OF YARMOUTH 2A
, ppliration for Disposal Works Tonsirur#ion lirrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (<) an Individual Sewage Disposal
System at:
..---•----...�....._--.___.......... --Locatio�....r.e.s.s...... _ ....._r_.L..._.,�...._.r Lt !- o.-3�.m x
Address
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, ( )
Other fixt----------------------------------•--------•-----•--.--------------------•-•-----•-•--------------.--- -----------
--------------------- _ `---------
Design Flow ..................... .. gallons per person per day. Total daily flow ........... _._._.._
....................... gallons.
Septic Tank — Liquid ca.pacity.A...gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length ............. Total leaching area .................... sq. ft.
Seepage Pit No ........ .,%....... Diameter....` ..... Depth below inlet ...... Iz.......... 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 ........................
----------------------------------------•-•---......-------••-•-•-•---•-•--.....--------------------•--•••------•--......-•-•-----••---•-••-••--•-------_....
Descriptionof Soil ........................................................................................................................................................................
---------------------------------•--•---•----------•--------------------------------...---•---•---------...------------------------------------------.
.............
Nature of Repairs or Alterations - Answer when applicable _.........------- f QSIa .......P.=.....L.-� ..�......."..
. Aw.....^/........_ .._.. ,JGs._......., �� �' T r�/`----------------------------------•-----•--•---•--•--....--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL, 5 of the State Sanitary Code —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beXb rdJ/�, health. /
Signed...-- L/ �. ���1..9
Application Approved By.... % y
/`l ate
Application Disapproved for the following reasons: .................................................................................._.._
.....................................•-•--...-•----....nn..........----.....------------..----•---••------•------•-•------•--------------.. 7 ------------------------------------
Date
..G
Permit No ............. .:....................... Issued........ _.---- .•..................
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irr#ifiratr of Toutpliattrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (�)
by........................................... t_Vi - c ............................................ ...... _....
Installer _
has been installed in accordance with the provisions of TIT 5 of The State'�itary Code as desc *be in the
application for Disposal Works Construction Permit No.___. .'°------------- dated....... "s . 7 ..............
,THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. ._.._..-- - -,�:,/ ----- ----------•-------- - Inspector--- -� C�J..11. -