HomeMy WebLinkAboutApp-Permit-Complianceo.
CrV
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appfiration for Disposal Murks Tonstrnrtion Prrmi#
Application is hereby made for a Permit to Construct
System at:
...�.�..
--- M...�. ..................... y ....................
- Location - Address
................................................
Owner
G-------------------------------------••--------...
Installer
) or Repair ( ) an Individual Sewage Disposal
--•1 r- . 3 .................... `............-----................
or Lot o.
...................................................... __.............................. _........
ddres
... �' j---7---.r61/� .�--&L 27.---- w --Y ........................
Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ............ 7_"W..9 .....................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures------------------------------------------------------.------...-----••-•-•---------------•---......------........------. --------------
.---..--------
Design Flow .................. IZO.................. gallons per person per day. Total daily flow ........... z. ......................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 .........................................................................................................................................................................
-------------•--••-------•---------•-----------------•-----•-•....._.....•--••---•----------------••---•--------------••--••-------:-.................----•-------......--------- =•--.....
Nature of Repairs or Alterations — Answer whe applicable ..... W.6 -W... 4kAZZC-----_,1..4-4.0....4ioi- --.....Ut'r ,qk..
._.........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 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 hftlth.
Application Approved By.._.
Application Disapproved for
Permit N
following reasoy:..
�
1y /--..._....
._.._.. ..-----.
Issuea.......
�.... . .1..... D�".....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD,Of HEALTH !�(
6rftfiratr
,..,"rtOWN of YARMOUTH
of Toutplittnrr
THIS IS TO CERTIFY, That the -Indwidual Sewage Disposal System constructed ( ) or Repaired (✓�
b----.....1 .�'.� 4 �J-• - G ..2, -V6 ...............•---...---...---•----
Installer
at.....................................................1...-- .....:5�& .. A11 ._.......X51:...f ..:-----------------...-----------..................•--...............---------
has been installed in accordance with the provisions of TIT 5 of The State Sanitary C e as d scri m the
application for Disposal Works Construction Permit i's . =2- �........ dated _....LZ/�—.... ...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ANTEE THAT THE
SYSTEM � L� FUC I)I SATISFACTORY.
DATE....................... ....... ................... Inspect ----.........