HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH (' '
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion Errant
Application is hereby made for a Permit to Construct
System at
--------------- ` ----� r .. ���......'�..........
-Location - Address
`4WO Oyyner T L
----'-----•^ ...... ......... ---------------
Installer
) or Repair ( f -ran Individual Sewage Disposal
- .. .-- ...---. ._.. ..............
`-- or Lot No.
---••---••---•__....�..._.._.. - \c . 6tn........................-------
Address
c� ►�`rz-r 2Q
Address
Type of Building 3 Size Lot... ......................... Sq. feet
Dwelling —No. of Bedrooms -------------------------------------------- Expansion Attic ( ) Garbage Grinder
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures.._.._...--•------------------------------•-----------.-----------•------------------------------ ---- - - --•-•-- --------
Design Flo ._....._. __. ....................gallons per person ger day. Total daily. flow_____`...... gal
�j.... . . ....... ... ions.
Septic Tank Liquid capacity/OCOgallons Length____ __________ Width.___....... Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ................... sq. ft.
Seepage Pit No -------- /_.......... Diameter_____. ______ Depth below inlet ..__.`:_IJ ......... 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 ........................
•------------------------------------------•--•--•----•---........-------------............_.._...--•--•-•---•---•••-••-•...._.._......•--•..................
Description of Soil__
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Natur of pairs or Alterations — Answer hen �a licable.... ._ S D 00 c� �-..� .`::.......
-.�... Pym 3.._'�p
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code — The undersignedfurther agr es not to place the system in
operation until a Certificate of Compliance hat heen Thh
e b(o�
Signed --
Application Approved By________ ___ _____ (�/ ___....�
Application Disapproved for t e following reasons: ___
Date
Date
Q� r- �s ss�� Dau
PermitNo .!........................ Issued.............1_.._� ..._..........
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrfifiratr of Toutplianr
THIS IS TO CERTIFY, That the Individual Sewgi /
by a Disposal System constructed ( ) or Repaired ( _)
--- �- .. w o _ ---------------------•---------•-........------..._._._.............---.......
p I.., ller
at- ........................................... 4. .�------.�..11_Y - ___ 1_�..�.1.__..4 :.. ---.._.......-----...._..----••-•------.....---------.......----•----
has been installed in accordance with the provisions of TIT 5 ofState Sanitary Code as d scrijZe in the
application for Disposal Works Construction Permit No._____ ::.. k.......... dated ......... _. T_--_�_.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE ................. 7 . �:.%�....•---------•--•................ Inspector---- �� .... - .: