HomeMy WebLinkAboutApp-Permit-Compliance, 9:2Z 00
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion 1hrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
i. ,
...................... . .... jj:r..Z..:P1j.5q ..... .......
Location - Address or Lot No.
.................................................................................. .
Own" c Adilress
...................
....... ... th ........ W.Mn .. YM.
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............... . V ................. Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria (
Otherfixtures ........................................................................................ .............................................................
Design Flow ........... 1/0 .......................... gallons per person per day. Total daily flow.......... ......................gallons.
Septic Tank — Liquid 'capacity.1000t.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. I ................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 ........................................................................................................................................................................
...................................................................................................................................... :: ................................................................
Nature of Repairs or Alterations —Answer when applicable__...0JKV.Q ......... A00-0 ... 0- ZX . ......
... 4a ... A0 -X ...... 1.0 Lk a W_rrk ... .............................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITIE 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 the board of h%lth.
Application Approved By
. . ....-•-•• � Date
Application Disapproved Wf9e folltfwing reasons: .......................................................................................................... . .. -
.....................................................................
Permit No......... ................................ .................................................................................................
.. 9. ....... Date
� .... .................... IssuedG_. .. .. .... .............
Data
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD OF HEALTH
TOWN of YARMOUTH
(9rdifirate of TOMpliam
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
by................................................... ..........................stal......ler .....................................................
I In
) or Repaired (&,�r
at.........................:.......................7..-1 .... .... fix-1.ox ...... C -4f ................. J-1,0 ...............................
5
has been installed in accordance with the provisions of TITLE , f The , a e Sanitary Code as describes in the
application for Disposal Works Construction Permit No ------------ 9-- dated ....... . .....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
nAq'R 9--2-4 — TriQnPrfnr