HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrwtion 11rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (V100an Individual Sewage Dispoossal
System at;- / / a.
Installer
Type of Building
Dwelling —No. of Bedrooms............................................Expansion Attic (
Other — Type of Building ............................ No. of persons.......................
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. I................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 ..........................................................................................................
Natu f epais or Alteratio ��`�Answer when plica le. tI/ Vj�i r....-- -
Agreement : l
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 has been isyss �d by theand of health
Signed. ..... l.�..
Application Approved By ....
...................
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Application Disapproved for ons:.-•.................................•-•----......-----••-•----•-- -----.-.�.•........�D..a..t.ee.
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....................Permit No. Issued ............. 7�.:..p. au ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(arriif iratr of Toutpliam
THIS -IS TO CERTIFY, That e Indiv idual,5eewage Disposal System constructed ( ) or Repaired
by........ .. . .......:. w... `:':'........ ........................................................................................
+. _ % _ Installer / . J z _ % .i J
has been installed in accordance with the provisions of TITLE e5 of The State Sanitary Code as describ d in the
application for Disposal Works Construction Permit No.... ,- ,.. dated .....
--.t.3...... .........
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS;. A�,G-JARANTEE THAT THE.
SYSTEM W�,dIL�L FU CTIO SATISFACTORY.
DATE..............1.....�... �......... ..i.. L................- ........... Inspector......:. ....... - .. .........................
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