HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tons#rurtiun jrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (J,,�an Individual Sewage Disposal
System at:
............. 3 .! .. ��- - ..1.3. NX .1 '.......................
/��ocation -Address /
wner
Installer
Type of Building
Dwelling — No. of Bedrooms,
Other — Type of Building ............
Other fixtures ...............,r
DesignFlow .-------• .......................-
Septic Tank — Liquid capacity.
Disposal Trench — No_ ______________
Seepage Pit No ..................... Di;
Other Distribution box ( )
Percolation Test Results F
Test Pit No. 1 ________________mi
Test Pit No. 2................mi
Description of Soil ...................................
-••-•-----•.............................._---...---•••••--•--••....----.................---------
or Lot
Address
----•-•----1�v� l
..-•.......................................................
Address
Size Lot ............................ Sq. feet
_:Expansion Attic ( ) Garbage Grinder ( )
o. of persons ............................ Showers ( ) — Cafeteria ( )
�rson per day. Total daily flow............................................gallons.
ngth ---------------- Width----------...... Diameter---------------- Depth--------........
------ Total Length .................... Total leaching area ...................sq. ft.
Depth below inlet .................... Total leaching area .................sq. ft.
by------------- ----------------------------------------------------------- Date ........................................
inch Dept 7 of Test Pit .................... Depth to ground water........................
inch Depth of Test Pit .................... Depth to ground water........................
------------------------------------------•-.......-------------•-----------•-------------------------...._...---------•--------............_......------------------ --------------------
Nature of Repair Alterations — Answer when applicable_.'Y G.._:f ------------ t
-------------------- ---
('i C' k � S'�►�--I 1 lh/2/ �i6 J �,.i�. � T,�t,z'i i'z c��C
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 issueddb�b the bo of health. qq
*Signed...• `.LJ••-----•.................._DatApplication Approved By---------- --------------------------------------------------•-------------- fir .�Zr��{ .
ate
Application Disapproved for the f ollo g re ons:--•------.....-••-••--•-----------------•-•----.......---•-•----.....--•--••-•---..._...........------........--
Permit No......-`._ �_—'
.-----------•.............................................................
_ OI Date
Issued.-- -•----- ......................•--......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH,
Trruftrate of TompltFtnrr
THIS IS TO CERTIFY, t t e Individual wage Disposal S7stem constructed ( ) or Repaired
by....................................... ..---G / -- --•---0-- � ..: �----:_..........................................----•--•-.............................._
Installer
at..... .....�,1.. E......�: f /... _._ i 19 nJ) ..•T7, ._... .G...._ `�...�L21,?_/� 1.r�.�'....................................
has been installed in accordance with the provisions of TIT 5 of H State Sanitary Code as describ }'n the
application for Disposal Works Construction Permit .-`• ..... dated.-..-�...^__ ?.� .1.•........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A 11-1 NTEE THAT THE
SYSTEM 1 WILL FUNCTION SATISFACTORY.
DATE •-• �-� ! .......................... Inspector.. .................
-----. --•-- ...........:..._....:.