HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appltlration for Disposal Works Toustru rtiott trrutit
Application is hereby made for a Permit to Construct ( ) or Repair (•--ran Individual Sewage Disposal
System at:..�..... ...............
t'oo -,A dress
..
.............................^'4r...........................................
... owner
Type of Building
Dwelling — No.
Other —Type c
Other
........................• ---- .� -:. ......... ' .
o.
N...... S..0 t .... _._.....
?k..1..:.tl....b?..--x.....44.
Address
Size Lot ............................ Sq. feet
of Bedrooms............................................ Expansion Attic ( ) Garbage Grinder
' Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
fixtures
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid ca.pacity............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. l ................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 ............................................................................................
of Repairs or
.......................................... ..... .. --
when applica leJ/15�.....Ib00. (�/') t�_
1 _.r.,....,.....:...z............ r- ... 1. ...... --------rt--.-,..,. : ................
........:.r..............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees aht to place the system in
operation until a Ce=ificate of Compliance has be • ued by the b rd 90J-11
L _����
p e
Application Approved ••-•••---.-•--• �4 �... __....
ate
Application Disapproved for the followinq reasons: .......................................................................................................... . ....
Permit No...... ::. J J .--......
.............................. •.........................................
I3aned.....
1 .. !., ._. G -----Date -----
D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(arrtifutttr of Tompltanrr
THIS IS TOC TIFY, That the Individu Sewage D;sposal System constructed ( ) or Repaired
by................................ Er....c.�' ........... -- -- ................................... ..............................
2 In taller
at..................... �� .......�;P...........5 ,............................................................
has been installed 'in accordance with the provisions of TITLE 5 of The State Sanitary Code as heschbed in the
application for Disposal Works Construction Permit No....40T
......` ;O.S....... dated.._... (-� .. _.1... 4� ��' .......
THE ISSUANCE OF THIS CERTIFICATE. SHALL BE CONSTRUED AS A GUAR T11;THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......... ...1..�........................................ Inspector.. ?� •-�! .������` •-=`'CLQ_'-l�:.r..---