HomeMy WebLinkAboutApp-Permit-Complianced �Y� �•. dz ft'
No...........'....... l , r" Fnx ...... ..... _.....
_ca y
THE COMMONWEALTH OF MASSACHUSETTSG`iL./SI�
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonotrnrtion liermit
Application is hereby made for a Permit to Construct ( ) or Repair (r�>4 an Individual Sewage Disposal ,
System at:
'6 VL_ lZb
NIOG 14
?5U
............_---....-----....---..... ......................... ..........1At..................................
ressorw No
................... .......!.A.........C/............. ........... ........._..... ........................................
O ucr Ls--7.LlJiSi.!(J.il '.76i �&J41�C..E`d-/ 1 .. /-1 /Yl /1�8�$
................................................ -------
....................................................................:..........................
InstaEer 1 r.g , 1 I ✓ Address
Type of Building 1 —^ Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms .............. .......Expansion Attic ( ) Garbage Grinder ( ) tib
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 ...........T... Diameter................ Depth ................
Disposal Trench —No ........... �....... Width. ....,i�'............ Total Length...... mss......... 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. 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 Soil...............................................................-......--
Nature of Repairs or
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 bee/n isssed by the ar health eg
Signed Ff ` ....................
�X
/ Date
Application Approved By.....1 ._. ' - .........
/ Date
Application Disapproved for the following reasons:............r'.......... .... .%_...................................... ............... .......................
...................................... .............. ... _...............................•-------------.......------------------........._....................---................---.............----
�+ ,,+Date
Permit No ....... FlFl__11135 . Issued .......: < 7.�� ' . :1.............
Date
_—_____._ ______—____----_--_.______._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifiratr of flrompliattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
-.. _.._
Installer
at........ - c 1 2, ..............1
v .- y .... ......
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 ....... :.:°.'m.�:- ._... dated ..............:.....: ^':.`�"°�r:..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. ef�,ip .f•"° Inspector.......`S.a�.:..�.<'.."..yY".^.......:'"�a`.r srr'...`:.�^`.-"..