HomeMy WebLinkAboutApp-Permit-Compliance8214
No._. _.. _....-_
THE COMMONWEALTH OF MASSACHUSETT
BOARD OF HEALTHti�
TOWN OF YARMOUTH
Appfiration for Disposal Works Tonstrnrtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (
) an Individual Sewage Disposal
System at: Ap
(l
49.... `' k ql
_.(4?- _m..0.\� ...............................................................
Aa Location - Address
+==Lr. .SE %C p. -L. -.....-----`---5_n-5 ..........................................................
............
or Lot No.
_.....--.
wner n
---------------QL�.V ..L.iA ......................... ............. --Q`=X-_`SL(
Address
................................................
Installer
Address
Type of Building
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.... .. ........................gallons per person per day. Total daily
flow.. 13.0. --.--.-.--.-----------------gallons.
Septic Tank -l -Liquid capacityL(.�.b--gallons Length: -,.Y ......--. Width._.'-..- ........
Diameter---------------- Depth------.--.......
Disposal Trench — No- -------------------- Width .................... Total Length..-..---------------
Total leaching area ... -........ ........ sq. ft.
Seepage Pit No ..... .(.............. Diameter .... j:,?-� .------. Depth below inlet../o--!----------- 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
Nature of Repairs or Alterations — Answer when
Agreement: r
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 been issued lly the board oaf health.
Application Approved
Application Disapproved for the following
--- -.........................
l z=`I
Date
4s i �� / G ate
Permit No. ...... -•-•--•--.-._..-..........---•--..-...... IssuetL-...-...... - ........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifiratr of Tompfianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (t) P
by.................................................................................
t ( n . __ Installer n.I
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as descrigdi the
application for Disposal Works Construction Permit No.--.--_=L� -:..�. _ _ dated... [' . -^ . � 1 ......
THE ISS ANCE OF THIS CERTIFICATE SHALL NOT BF -CONSTRUED IIS A GUARANTEE THAT THE
SYSTEM WIL FUNCTION -SATISFACTORY.
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