HomeMy WebLinkAboutApp-Permit-ComplianceNo.......: ✓. =` Fan. °......`..`...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal lVarks Tonstrnrtion f rrm t
Application is hereby made for a Permit to Construct ( ) or Repair (:/an Individual Sewage Disposal
System at
Jy^''r'��oeagon Address i y / ¢'Y a Lot No / y,d�7,p
/ k'°. 4 rf £Y°�✓al.a' ......... ...... .: .... !:_.:x'..k `���..: �:i.A 51.° 3 C �.t�3
tW.i ..... ."".'''—✓p }"� .Owner �. may. e.'''j..:.,,. r� % m°�.xe...%�:". �JVG" ✓ a'-a✓r✓t' �.
..... �.x Y ................... ... 0.....�i.........,
Add
p� Installer Address
6 Type of Building Size Lot ................... Sq. feet
aDwelling — No. of Bedrooms.. ...........:............:................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4
Other fixtures .........................
W Design Flow............................................gallons per person per day. Total daily flow ....... ........ ............................. gallons.
wSeptic Tank—Liquid capacity ............ gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length.................... Total leaching area ... ......... ........ sq. ft.
3 Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
.a Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ly Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Descriptionof Soil........................................................................................................................•----...........................................
Nature of Repairs or Alterations — Answer when
"7':.? lz.?4 / i /D.. n_e" N
Agreement: i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIN S 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 bo; rd of health.
Signe
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Application Approved By..... I.......... ... .... .: �_: 1 8�? ? ...._ya/.D13. .......
Date
Application Disapproved for the following reasons:-----•-.............................-------..............---.............................................._
Permit No ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irrtifirab of Tomplinurr ,
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (� }
has been installed in accordance with the provisio of TITI of The State Sanitary Code asydelcr}bed in the
application for Disposal Works Construction Peralt No ........ ....... dated.......�:e�i .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL /lrUN )OTI,ON SATISFACTORY.