HomeMy WebLinkAboutApp-Permit-ComplianceNo._._ I . J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fss ...............
Appliration for Disposal Works Tonstrur#ion rrruti#
Application is hereby made for a Permit to Construct ( ) or Repair (� Individual Sewage Disposal
s at. �,
. . .. . .. . ..
n Address, 4.
_��.
Installer
Type of Building
Dwelling — No
Other — Type
. of Bedrooms .................................... Expansion Attic
of Building ............................ No. of persons ....................
Size Lot____________________________ Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Otherfixtures.----------•-----.-..-•.---••-•---•-------------------.---•-----------
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity____________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. 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 - Ans e when plica e__
- --- .- y-----�----------------------------------------
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 not to place the system in
operation until a Certificate of Compliance has been by the board
g-�
Si ned_._ ........ ............._...
Da//
Application Approved By.... --• ••---- •- -- -........ ......... -• ••••-•--••-------•---•---••--•------ 3...--•--
Application Disapproved for the ollowing reasons__________________________________________________________________�--____/______/-Dat-e--�� ________..._________
................................................
Permit No ............ .... .�3................ ...._
-13
Date
N0
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(grx#ifiratr of (omplittnrr
TgUJ-To
C-ERT That the I d:vidual Se a D' posal Sy tem constructed ( ) or Repaired
by.... -�- �::_.: .rs..:.�-?l (.L..-c?.a?�!.�i............................................................ .......... _
/7.�e.. Installer
has been installed In accordance with the provisions of TI of The State Sanitary Code s d crib in the
at
application for Disposal Works Construction Permit No___________ ____,______.... dated .... ._.t�_ . ___8 __ __ _.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A,GUA AN EE HAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
-- �- F' - .......... Inspector-... �....1 .. .� .L --------------------------
DATE