HomeMy WebLinkAboutApp-Permit-ComplianceNo..--- -(---- Fss.....7 5...Qfl.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
d';� 3J
Appliratiun for Disposal Marks Tontrnr#iun 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
----•----•---48 Elton Rd . S. Yarmouth, Ma . 111 q0- 2_2 •-•---•-•-•------------•..............................................
___...._-•---------.. ....- ...-......................... ........... .
Location - Address !A Gs Q or Lot No.
...............................----------.......--.............-•----------............................
aQzOwner
�'V ���� 1 Al �d�-� 215 Ost. l�arri. Rd. Osterjrille Ma.
- - - --._.........• --
Installer *Address
Type of Building
Dwelling — No. of Bedrooms ................ 2 ..................
.
Other — Type of Building .......................... No. o
Other fixtures .... 4_�,----- .......................-
Design Flow --------------------------
Septic Tank — Liquid ca.pac
Disposal Trench — No. -------
Seepage it No* ---- ox ------
o...........
Other Dist ibution box ( )
Percolation est Results
Test Pit No_ 1 ..............
Test Pit . 2 ...............
per person �er day.
................
Dosing
nor d by......
tes p r inch
tes De inch
Depth
k( )
Size Lot ............................ Sq. feet
ion Attic ( ) \ Garbage Grinder ( )
.... Sho ers ( ) — Cafeteria ( )
Total daily flow...........................................gallons.
'dth--------_----- Diam ter---------------- Depth ................
*.................. Total, eaching area -------------------- sq. ft.
t ................... Tptal leaching area ------------------ sq. ft.
----------- -----------................... Date ............................
of Test Pit .................... Depth to ground water ............
of Test Pit .................... Depth to ground water............
............... ---'A-•.....----.....•-------.........--------.._....•--------------•------------........---------------------.............
s — ....tea riDescription of Soil- ------------------ ----------•----•.-.
..............................--------------------------
-------------------------------------------------------............------....----------.............------......
Nature of RepairsorAl-doAnswer when applicable ..... �.5Dd... ga,l_]_on.... ... arx.m-i.th......
threestone a�bkedinfiltrators• �•-•---.... ---------------------------
_.. ..._
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 Certificate of Compliance has been issued by the board of health.
e
Signed-----
Application Approved By .....^ ?rs
Application Disapproved for the following reasons: ...........
`t'S = CO I
Permit No ........................
C?t
Date
r ---------------------------------------------------------- —
.-------------------••--------------•-------•---•-••---•---•-----....-•----
/ %
Date
j (�
Issued ••----1 ?t '•-1. ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrfifiratr of Tompliaurr
THIS IS TO CERTIFY, That Individual Sewage Disposal System constructed ( ) or Repaired (x )
by......... a'- - ----------------•--------------------------------------------------------------------_----------
Instal ler
at........... 4.a ... Elt_oxt...Rd... ---------------------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
------------------- dated--- � 7 ..
application for Disposal Works Construction Permit �'o.-._-y
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector ....................................................................................