HomeMy WebLinkAboutApp-Permit-ComplianceFmc.................... . ...... .
THE COMMONWEALTH OF M'OA SOACL HLJ6ETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Uhipwial Works Toustrurtion Vautit
Application is hereby made for a Permit to Construct or Repair tan Individual Sewage Disposal
System at: to 10 6
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Y. tion
tio (L ............ --------- _1&N10Q6 ... ---------------- * - -
Owner Address
.... . ... .... - -- - --- ------------------------ ----------------------------- * --------------------------- * --------- * .......
in*stalle; Address
Type of Building Size Lot ............................ Sq. feet
ion Atti Garbage Grinder 00)
Dwelling—No. of Bedrooms ............................................Ex
Other—Type of Building ............................ No. of ons ........................... Showers Cafeteria
P4 Other fixtures ......................... -•-••-
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..... ......... ................................. ......................................................................
Design Flow ............................................ gallons per son per day. Total ily flow ............................................ gallons.
9 Septic Tank — Liquid capacity ............ gallons ength ................ Width............._ Diameter______.......... Depth ................
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xDisposal Trench — No . .................... Width......._........... Total Length ........ .......... Total leaching area .................... sq. ft.
Seepage Pit No .................... Diameter..._..._.__ ------- epth below inlet.........._........ Total leaching area .................. sq. ft.
Z Other Distribution box ( ;os g tan
Percolation Test Results Performed y .................. ........................... .......................... Date ........................................
Test Pit No. I ................minutes peri Depth Test Pit___._.............. Depth to ground water..__......_..._......._.
Test Pit No. 2 ................minutes per inch Depth o Test Pit ........:..._._.•_. Depth to ground water........._.._...........
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0 Description of Soil----------------------------------------------------.................. ...............................................................................................
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Nature of Repairs or Alteration4 — n wer when applicable ------------------------------ I ------ . ..................................
Repairs -
A --Ir— ..............................................
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Agreement:
The undersigned agrees to insta I th aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of he Stat Sa itary Code — The undersigned further agrees not to place the system in
operation until a Certificate of m lian e h s ee issued board of health.
ann
Sign . ........ .. ......... .. ...... . ...........
5
)at� .`tab
ApplicationApproved B .... .. ..... . ..... ............................. .. .. ................... ...... .......
Date
Application Disapproved for e fol wing reasons: --------------------_- --_-------- ---------------------------------------------------------------------- -
........................................................ ......... ............................................................................ ...... .....................................
_—Date
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Permit No .... l c .... ....... ....... ................. Issued .......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifiratr of (gautplitturr
Repaired
by
TOC That the Individual Sewage Disposal System constructed or Rep
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at ..... t.& .... . . . ...... .... ........... .. . . ...................................
has been installed in accordance with the provisions of TITLE of The State Sanitary Co -1- as delcr' ibed in the
application for Disposal Works Construction Permit No.._ ............ da
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THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector ....................................................................................