HomeMy WebLinkAboutApp-Permit-ComplianceNo.....-!. Z..13 Fze$Z6 . Cc,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Warks Totts#raxc ' n rrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: t JjjI
�j��/y��
MLAddress
a
-------- . _ - — '. — .. ........
Installer
T e of Buildin
or Lot o
da ess
......--.... e Y'So.,
....... ...... . ------
- - . -
Address
yP g Size Lot............................Sq. feet
Dwelling —No. of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder ( )
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 ................ 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. 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 ............................................................................................
.7 .......................................................................................................................................................................................................
--•----•---------------------------------------------------•-------------------------------.........._...-----•---•--.._.._ ... .. •-••-•--.... -....
Nature of Repairs or Alterations — Answer when applicable_ � W _................�' _ ... -----------------
l.S. .... �.� ..... :...------..I--• -T�='-30>= (a o '------ u....... LA..a...... �...5. . .
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 'AI A' 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 by theboardof health. S
Sign -s.... ..0 SC .......................
-•--•--
Application Approved By .............. ............ -- ..................................................
............................
Date
Application Disapproved for the following rens n................................................................................................................ _
Date
............... Permit No.- -2 ._...... .. Issued........- .# --- `----•--........_....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifirtar of TnntplianP /1'
THIS IS TO CERTIFY, That a Indivi ual Sewage Disposal System constructed ( ) or Repaired (1/)
by.... . 5... -i ....... ... . .... ......................................................................................................
Installe
at % .. tZA.�G� 5...._G✓h ... �j''1✓ 1? : Etta
irk6 -
has been installed in accordance with the provisionsof TI 5 Qf St el& nitary C ie as les in the
application for Disposal Works Construction Permit No !_G -r _.1_ .__.... dated......_. �2, !..... ' __...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT, TRUED GUARANTEE THAT THE
SYSTEM WA FI N�CTI",SATISFACTORY. I B 1