HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for 14sp o sal Works Tansirixr#ion ramit
Application is hereby made for a Permit to Construct
System at -
....9... e b,e .........................
tion Address
...............................................
.• •- I :d._ �._ .. wn . ).::. ........................
.� Installer
) or Repair Individual Sewage_ Disposal
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A reas
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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 ........ 110...........................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity/ gallonsength................ Widt� .............. Diameter ................ Depth ................
Disposal Trench — No. .: .................. Width............._ Total Length___. Gl.......•..... 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........................
Descriptionof Soil ---------------------------------------------------------------------------------------------------
.... ............. ......................................•• .
Nu a of Repairs or Alterations —Answer when applicable% �....T .4:. �' ..1-?. ......�.��..]OW .. �
s�. -�.............................................•-----•-••---•-•---•-------•----•-•--...........---•----••----•-••----....................---.......---••• .........................
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 agr es not to place the system in
operation until a Certificate of CompliaKe has �a@ i th o�eakh
Application Approved Bye...:........
Application Disapproved for the following reasons: ............
Permit
THIS IS TO
......1.
..........
Date
Date
t
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifirit#le of TI-Implittnrr
IF, Y, That ,thee Individual S,gwage Disposal System constructed ( ) or Repaired
by............................`�.. ! ...1. ! ..l.1..SJ.l. .! �: _.%.j.�/. d..:..-•---...-----..............................................................•..................
(S -ti Lac /W.." ns a
at....-•--.--•---••.........- ..........�.. -
has been installed in ccordance with the provisions of TITLE 5 of a tate Sanitary Code descr ed in the
application for Disposal Works Construction Permit No.....g'3-=5- ........ dated.._....��... ,..�.�..'n.........
THE ISSUANCE OF THIS CERTIFICATE. SHALL T BE CONSTRUED AS A GUA ANTE THAT THE
SYSTEMA WILL FUIJCTIQN SATISFACTORY.
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DATE............�:e.....��
�r........�. ...............................