HomeMy WebLinkAboutApp-Permit-Compliance'rM 1-0
2 1'2�,
No. ...... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appitration for Disposal Murks Tonstrurtion "Frrmtt
Application is hereby made for a Permit to Construct
System at:
Location - Address
PA..QAo ................................
Own,
. ..............................................................................
Installer
Type of Building
) or Repair ( t4 an Individual Sewage Disposal
............ .......... /
... 29
or Lot No.
........................................................................................... . .....
Add Ess
Address
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ........... -3 ............................Expansion Attic ( ) Garbage Grinder
Other—Type of Building ............................ No. of persons._................_..._..... Showers ( ) — Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow .............. . U 17 ...................... gallons per person per day. Total daily flow ......... 3-1.0 ....................... gallons.
Septic Tank — Liquid 'capacity.-JOCC._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 ........................
Description of Soil...
......................... ............................................................................................................................................................ .............
Nature of Repairs gr Alterations — Answer when applicable ...... .
V,
&a;
......... TV
Agreement: .4 Prt- W t>t-6 YA E�' >yz_'o k tk) S t
a Disposal Syst m n
The undersigned agrees to install the aforedescrited Individual Ses e i orda 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 issued by the board of health.
i ed- . 1 ..
. . .......... C- . ..................... ...
Application Approved By... ... ........ ....... ...... 1 -
Application Disapproved for the following reasons: .................................................................... ............ -------Dat --------------------
...-•-•-• •---- • •--•-•-• •--•..... .......................• ----• •................. _..•--...--•------._.. _.
-----------....................................................................................................... ........................................... ...........Date--------------
Permit
..........Kte--------------
Permit No .......... 9 .. .................. Issued ............... .... ............... .
.... ......
a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 6y—
TOWN of YARMOUTH
Tntifirair of Tompliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by........... ................................................................. 16_2! 1"'i -------•-•----...............---•••--........_.-•------......----........... .......................
Installer f
at....................................................... ------ ............ ................................
has been installed in accordance with the provisions of TIT 'of The State Sanitary Code Is desckibe in the
Code
45
,application for Disposal Works Construction Permit N, 7.&?.. dated.....---'
..... --------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR NTEEITHAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ....... . . ..... ................................. Inspector .. ..
.... .. .....
)r
........ ... .............. .......