HomeMy WebLinkAboutApp-Permit-ComplianceNo.__Cfl . Z.L . Fim.......... ` .._..._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Di"nottl Marks Ton,strnrtinn Hermit
Application is hereby made for a Permit to Construct ( ) or Repair
( 71) an Individual Sewage Disposal
System ata o+'
.160 QqA Dlain Street, So. Yarmouth, Ma. ........... LVL_
_..__............L ...........ddress.............. -.E5 ... !nIca.P:4?.!...__..._............
. Location. Address ....-" ..............................••..
..............................................................
or Lot No.
Owner
'
Cas:........................................._
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 ( )
Otherfixtures..............-------.............----....__................ .....
_...................... ........................................
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank—Liquid capacity ..... ...... .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
Nature of Repairs or Alterations — Answer when
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLI. 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been . u by the board o iealth. 7
�-. _ 04-11- 1
Sig d.: ................ . . ........9......
ati
ApplicationApproved By.... - - - - -. --- -------------------------------------------------------------------..........G�..:.......::................
Date
Application Disapproved for the f lowing easons----.... ---................ -.....................................................................................
// G/ Date
Permit No.....!............................................. % { -/6
Issued................t..._................ _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
_ Tertifirttte of Toutplittnrt
THIS .IBP,YCF�u�FkY�YThat t�tt1Cndividual Sewage Disposal System constructed ( ) or Repaired (X)
by ....................... ....r ..........................................-----•--•-----------....................----........................................................................
Rio ,.�....... � � tall n
160 Nain ,street, South Yaf+itoF1th, M1. (Samuel Wok)
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._qZ.- Y .................. dated.....
THE ISSUANCE OTHIS CERTIFICATE SHALL NOT�BE CONSTRUED AS -A GUARANTEE'TH THE
SYSTEM WILLf NCTI F N SATISFACTORY. � � •� (1
.,,
DATE. ...............i.-•----..................................... Inspecto?. ':........ ..... ........ ::..............
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