HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH L"
TOWN OF YARMOUTH
Appliratinn for Disposal lVarks Tonstrurtinn f rrmit
Application is hereby made for a Permit to Construct ( ) or Repair (> an Individual Sewage. Disposal
System at: 141
................_..! .'_... huxcti....Sl:r. ��:..........- ------............. ..1....`.......-.- - - -- °-� --............................................
Lo ation - Address 9 6 prewou or Lot No.
................ % ' ' t� c r.... '�.AL s.l_CrS 9.s` ..... ...........................
owner
3� a rAddress
..................
.........................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms........�hf Vte ......................Expansion Attic ( ) Garbage Grinder (P0)
Other — Type of Building d. islar.. Z as..... No. of persons........... A .............. 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. 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 77- Answer, when applicable ...................v..........................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIZ 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 boar of health.
Signe Al f et. ....................... �.. 6�..../.
fApplication Approved By.. ..•.... -- ........................................ 3
Date
Application Disapproved for the following reasons: ........ g .......... /..........................................................
....................••------...---.......................--------•--.......---•---------•---.....-------•..-•---....................------------....--------------------------------- -------------------
Date
PermitNo ...... ..................•------............ Issued............ �_:.1.. .._................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH���
flrr#ifiratr ,af Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal S�-'stem constructed ( ) or Repaired �)
.. 1Rrma.� ar.
by............................................�.�.s;,.5... `1cucklna.S�...�.:..:�11..�3ox �:.f-•- �'--.........._..............................._...._
Installer
at..............!f............ -- -----------------•-----•-----•-----•--------•-------•----------•---------------------•-----------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....5.�6_:-::l..................... dated ...... /-�' % ...............
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FtjNCT1PN SATISFACTORY.
DATE...............%... ................... Inspector.. - -•................ --•--•--•--
f