HomeMy WebLinkAboutApp-Permit-ComplianceNo- _....Fss.....i..S ..:_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Disposal Warks Tonsirwtiun trrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
Sys at:
............._........... .................!�, .
ti
....
CLocati n Address r or Lot No.
OwnerAddress
Installer Address
Type of Building Size Lot.... ®�.... .. _._Set:-•ket
Dwelling —No. of Bedrooms..........:..s .......... 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/a! ?gallons LengthO.:�G_.. Width.5.-_O -- Diameter ................ Depth_44,. k ..
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No ......... ........ Diameter --- ,l?......... 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 ........................
---•---------•-----------------------------------------•-----•---•------------------..._.........•-------••------••--------------•------......._.......----••
Description of Soil..
-------------------•---...--------------------------•---------------•-••--•-•••-.-•---•
Nature of Repairs or Alterations — Answer when
./(n -- ----~- t`.�.:��'�.?... ---......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi. 5 of'the State Sanitaode The undersigned furthe agrees not to place the system in
operation until a Certificate of Compliance has been issue by the boa42 he th /
Signed ---- ........................ .//!Z
Application Approved By--• ..... ... .............. ............. ............... ............................ �. 2ate'*
Application Disapproved for the following reasons: .... ............... -----•---•----------------------•-----...---------....................----................
Permit No ......... S.ZIR15 ....... --....
Issued...... ` s~.a�......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifiratr of Toutplittnrr
TW- IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by...... ............ A ........... r....�.s�.....%:C�`r.�� -� •--•-•--------------------------------------•--•----------..............-•--••-----------•--.........----•----•--
cf Installer
at........ � �J .1.:..-..--•---.......-----•--•-------------------------------------------------------------•--................
has been installed in accordance with the provisions of TI�TjLE 5 of The State Sanitary Co& as described in the
application for Disposal Works Construction Permit No..._?11 _.�. 5 .................... dated-...S.jl.._�:.)_I�-_.._....._._.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANT E THAT THE
SYSTEM WILL F NOTION SATISFACTORY
DATE........:. -. �.1- .....: ....................... Inspector .... .._ ............ :.....: .............:.......