HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion Vrrmit
Application is hereby made for a Permit to Construct
System at
-- Location • Address
...---- 1.�.t4.�................•--•-•-----••---......--••--.......
,..owner
- ................
............ ........•-•...
Installer
) or Repair ( ) an Individual Sewage, Disposal
........................1. = , . �'..........tp 3 I.......
-� �. or Lot No.
Address
Type of Building 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/600gallons Length.87.-!.;."". Width ............... Diameter ................ Depth ................
Disposal Trench — No ..................... Widt .................... Total Length -------
...... Total leaching area ...................sq. ft.
Seepage Pit No......../......... Diameter-_ .. Y.Z6.. 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.............................................................
........--•...................•-----•---•----......--....... .. .
.....................................
Nat�t of Renaks or
Agreement: V ' V , V f/
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasbm issued by the board of he 11th.
�_.�_�_.�X�?�....11��.!-��...
Application Approved By... ........................................................ V V/... .... _....
Date
Application Disapproved for the f ollon reasons: ......
..............'Permit No......... ��...... �. �..------.......----...------........----................Issued.......... ......
.. !!.�......
Date
THE COMMONWEALTH OF MASSACHUS€TTS
y BOARD OF HEALTH
TOWN of YARMOUTH
(Irruttratr of faoutnliaurr
THIS—L93—T-01 CE TIFY_ ghat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) M
by....................t i ` -/-%
...^ ..... ..............Installer .......................
......................
................
.................................
has been installed in accordance with the provisions of TITh , of The tate Sanitary Code s describ d in the
application for Disposal Works Construction Permit No --------- .�'.� .=--�.-I-� ----• dated ........... .r.�,,5 .. ��...
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUAR TEE T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ .%............................................ Inspector....... tl s�. ......----.. ......:.......