HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1-..V .�.. Fxs.. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tons rixr�' n rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
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tem at
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F✓ ion - Ad ress `� r Lot --
.._..:1� 2�-_�1_--n. .,Q... e e ..... . ............ s ._...,� r1!_-1 �!....---------........-----------...---...
Owner Address
------------------------------------------ ...... f .lrl 'wj/..............................................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms. -.. ................................Expansion Attic ( ) Garbage Grinder
Other — T e of Building ...... No. of persons ............................ Showers — Cafeteria
Other fixtures ...........................
Design Flow ....................................... ....gallons
Septic Tank — Liquid ca.pacity...........gal
Disposal Trench — No ....................
Wid
Seepage Pit No .....................
Diame ......
Other Distribution box ( )
I
Percolation Test Results
Performed
Test Pit No. I................minutes per
Test Pit No. 2................minutes
per
!rson per day. Total daily flow............................................gallons.
lth--•............. Width ................ Diameter.------------... Depth ................
.... Total Length .................... Total leaching area ...................sq. ft.
Depth below inlet .................... Total leaching area .................. sq. ft.
►os ng to ( )
b---•-••-----........................................................... Date ........................................
in h Depth of Test Pit .................... Depth to ground water............--..........
inch Depth of Test Pit .................•.. Depth to ground water ........................
Descriptionof Soil........................•--------•------•------........-------------•----•-•-----..-----
........-•.....................•------.....--........--........--------------.........---...........-------•-•--------•---......----•---........-------------•----•--.••---
----•------------------•------------------•----------•----•--•---•....•-•---••.........------------•----------------------------- .._
Nature of Repairs or Alterations — Answ L whe a plicable.�t!. W� � G�
tL, 'd ---
................................................... .. .....................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 thoard of health.
Signed..
Application Approved By
Application Disapproved for the following reasons:
Permit No... `�` .
,7-/ '/-Fs--,-
.......... .......................... _....
ftes�
Date
.------------------•-----•-------------•--•----...................---......
Date
Issued.-----.... .lam- ............
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irr#ifirate of ToutpliUM
THIS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (;/)
by ...................... �tl L..��....."C.�G1�--------------------•-------......-•-----•-------.............--------...•..............._..........
.. -
_ / Installer
at. ............... _- . _ ..1. : .....
has been installed in accordance with the provisions of TITLE_ 5 (f The State Sanitary_Co a as/
sescrihed in the
application for Disposal Works Construction Permit No.__� _.:_ ___ r .............. dated__.. '. Lf _ fc`,%'_I....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
nA'r7 1 . C/; �_ Tncnerfnr ' I %� .� _..,% �.'l J/t ✓ %�..., ( ''( .'