HomeMy WebLinkAboutApp-Permit-ComplianceFzs.... 1.,.5..... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion V motif
Application is hereby made for a Permit to Construe
System at:
r..»!..�::........-1°=...... ».....
Location - Address
.........................................
Owner
.....1. . ....... FA n�»eo.................................................
Installer
T e of Buildin
) or Repair ( � an Individual Sewage Disposal
or Lot No.
............................................................ •--.........................»........
Address
.......................
A cess
yp g Size Lot ............................Sq. feet
Dwelling — No. of Bedrooms._.' � .............................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ 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 .........................................................................................................
---•-••-•-•-----......-•--•-----•------•-•-----------------------•--•-••---...........--•--••--•-•..............•---•-----.....-----..._.
-----•-•-•-•........................................•----...-..----••-------•----.......-•----••.... ----
Natu a of Repairs or lterati ns — Answe whe applica le--____.._._�r._....
=...Q--�a ..JPO.. l ... ..._... ' ca��..F
Agreement:
The undersigned agrees to install the aforedescribed Individual
the provisions of TITLE 5 of the State Sanitary Code — The anroar� operation until a Certificate of Compliance has ll�sued by the
Application Approved By... . -.-. __..-//
Application Disapproved f or+%the following reasons:
Permit No..... -•-_s - i!- b.........--•---........
Sewage Disposal System in accordance with
ned further agrees not to place the system in
of health.
l._ .................. .._
..................3 --------
Date
Issued. .......... i ............1�... au ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrfifirate of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (p -y
by .......... .. ".. ...Q_C'...................................................... .• ..........-• - -...-........._....... ,...........---•- -
----------- -
') Installer
at........?.7 -yll..l.-2..1g t.. ...... �1.Vjs...---------•----...............-•--•..................................•------................................------.
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as describe in the
application for Disposal Works Construction Permit No.......(_%7j^-.(._��.......... dated.......--�,�,,"�..........
THE ISSUANfCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED $ A GUARANTEE THAT THE
SYSTEM WILL.FUN `T10ATISFACTORY.
DATE.. i. ' 1. r 9 Inspector .� r S.... � }... ....i 1...........:".
4.