HomeMy WebLinkAboutApp-Permit-ComplianceNo. Fss.�� a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratinn for Disposal Works Tonsirnr#inn ' f anti
Application is her b made for a Permit to Construct ( ) or Repair (14 an Individual Sewage Disposal
System at:
................ -__. .. .. ...........-.r. ...... ------------
L,o��cat•ion� • Addres
... ...... h! .. ......
.. ...........................
....._:4��.�!{���.---•.�wn---•- •- •- --X__-----= -•--------------
Installer
mqP-109
...._.._ .............. ..-----.. .....__..._ter.: u�a
Of-
.......-----�-•--.... ----�.....:.. ..........�-:
Address
Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms .............. 5;Z .........................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No, of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures
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..............................................•......................I..... 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........................
Descriptionof Soil..................................................•----------------------......----------...---------------------•------•---.........----..............---..........--••
-------------------------...---------------•------------.......-----••------.. ..----.--•-.................................. -
N tore of airs or r tions —Answer hen applicable. -I. -X45- :.. +. .
__t
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I711Z 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss d by the bAard of ie�alth.
Signed..... _............................................... .......................... -....
Application Approved By .... ----•-• /..... ate. ----
Date
Application Disapproved for the f ollowii�[g reasq.46: __.
Permit No ......... i .......................
�C� 7
Issued ......'__-D. ..:_1..E_- ...... ...�..... ..
Date
THE�f,O �ON'V1tEACTH OF MASSACHUSETTS
OAF�D _?F HEALTH
T N of YARMOUTH
f�rx#ifir trlarf 'TnntpliMMIT'
THIS ITO CERTIFY, That the Individual ewage Iii osai.,System constructed ( ) or Repaired (V)f
by ............ �1 .:: /I ..r... .. _..............
- - • -..._------•-•------•---•................................. .......
Install - V
at. ... 5' _.. ,.r.�'flJ'. P -:._.. N ... 1-� �� '', .
........... :. .. .2 ........---•-----------.....-----------...-----...........------
has been installed in accordance with the provisions of TITLE 5 of The -State Sanitafj Code as described in the
application for Disposal Works Construction Permit. No ........ ,.--_.'.- ........ dated ...... Z ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO RUED GU NTEE THAT THE
SYSTEM WILL/FUNCTION SATISFACTORY.
DATE ...1 `..... ... Inspector...... a- --