HomeMy WebLinkAboutApp-Permit-Compliance:;;
No .9-1 �.....`4 Fxa! ..... ......
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appluttfion for Disposal Works Tonstrurtiun Errant
Application is hereby made for a Permit to Constr
System at:
.........1.. ......:?`!!A -i? .%...............
Location - Ad ress
..........._. p c .!�<�LfE ..............................
Owner
.....--da `...........0 � c�--------------•.......--------------.............
Installer
Type of Building
Dwelling — No
Other — Type
Oth
uct ( ) or Repair (�an Individual Sewage Disposal
. of Bedrooms...: 3 ...................................
of Building ............................ No. of
..YAR �N%o U T PCIA-f ;Z�� LDT_ le.'4 r —Ile+
or Lot No.
-•---------------•--..................----...-•------•-•..........................................
Ad ress
Address
Size Lot ............................ Sq. feet
..Expansion Attic ( ) Garbage Grinder ( )
persons ............................ Showers ( ) — Cafeteria ( )
fi t
erx ures......--•---•-••----•---•.................••---•-----......----•----...........---••----.....---....----....----••------•-------------•-----..........
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ca.pacity............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. l ................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........................
Descriptionof Soil-----•--------•............................•---.......------•----............----•----•---•-•--.....--•-•-
--.....................................
.... -- -------------
N ture Repairs or Alterations Answer when applicable...__.i�........................ �`�'1?..f ��.� ab_..._ ...............
-----------------�------....................-----............................ _
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanit Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha bee ilssued by th bo rd of health.
Application Approved
Application Disapproved for
Signed..`..... ........................................ 1.2 3 %�
Date
. -- ::_K"
................ ..... '�
1 -.�'
Date
Permit No.........�.:.1.`_:.j.��.�..................
.............................................................. ...............................
.................................................... ...---..........--•----•---•---•--•-•---
Issued........ � ..L...
.... .....Date .•....
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
arrtifuttt�e of (anutpfinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( y�
by....... 1.1: ...... C A-U-C—a...........................................•------•-•---....---..........................................................................-••-•---
Installer _
has been installed in accordance with the provisions of'T
application for Disposal Works Construction Permit No.__
THE ISSU#NCE OF THIS CERTIFICATE. SHALL
SYSTEMA WILLI FUN ON SATISFACTORY.
DATE....... .. t) . ? .:........................................
..� .
IT 5 o hee State Sanitary Coac. as deesffcri ed in the
---1Z- 7-42 ...... dated =.TI, Jam-.
NO BE ONSTRUED AS A GU RANTES THAT THE
= � -�
Inspector..... ..........:.........................................