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HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS Q, BOARD OF HEALTH TOWN OF YARMOUTH Appliratinn for Disposal Works Tonutr #tun jhrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ddren Owner ._.,z..?_._...._ ...* Installer Type of Building Dwelling —No. of Bedrooms ............. . ............................. Expansion Attic ( Other —Type of Building ____________________________ No. of persons ....................... Otherfixtures -------------------------------•---•------•-----------.------•---•---••--•••--------•-•--------------------•--------•---------•---'----.....----...--- Design Flow -------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons. Septic Tank Liquid ca.pacity......_.__..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 ........................ Garbage Grinder ----- Showers ( ) — Cafeteria ( ) Descriptionof Soil ...................................................................................... --------------...---..........---•--- N urea Repairs or Alterans — Answ r hen applicable ---<Y._^ ______-____ :�_-::.�................. Agreement: 0. C�F„ Z �. «rc s Py , c �j �.�lC i S v ,- r C The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code — Thundersigned further agrees not to place the system in operation until a Certificate of Compliance has been is bythe bgarnf •�laeal►� --------------- .......... _.. _.....` . la ate Date Application Approved Application Disapproved for the following reasons: ............/_____{__________________________-_________________-___________________-_____________________ .................•-•--------••••-------..................._.�--j-�•---••--•---•••------------..._...._........_...__.._...••••-•••...••••••-••••••••________________________._____.-___...___••---------- Permit No . --'Q ....................... IssuecL.- - Date ©�Df— ...................... ate ------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH Trr#ifiratr of Toutpliattrr TO CERTIFY, Thaj4he Ind vidu,1 Sewage Disposal System constructed ( ) or Repaired ( ) — �i f-_!s/d'/_alley at----- f --^----•------• has been installed in accordance with the provisions of TIW:f_ 5 f e State S application for Disposal Works Construction Permit No ..... s ______________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED SYSTEM WILL FUNCTION SATISFACTORY. DATE ...................... ? • C ------------------------ Ins ector_.4Z�?�: T THE