HomeMy WebLinkAboutApp-Permit-ComplianceFss.........
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. THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tons rn.t#iun 11rrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( V� an Individual Sewage Disposal
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Sy,stegp at •�-`'
: :cel z. �.......................•-•------........---------•
L tion . Address
Owner
Installer
Type of Building
or Lot No.
1^�
Address
Size Lot............................Sq. feet
Dwelling —No. of Bedrooms....... . ................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ---------------------------- No. of persons ............................ 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. l................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--•......................................•---•----•---------•-•--••-----------------------------•------------•-•--.......---•--......:-----.....................•..---•-
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
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Signe ------•-• ---- �...................
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D to
Application Approved By.. .............. _..-..�...� Z_ ..c'E..�
Pate
Application Disapproved for the following reasons: ................................................................................ ...............................
--•........................•-•--••----------•---...........--------•---....-------•----...---------.........----•-...•........------•--•--••-•-•-••-•...•---........ ............... ---•-•..............
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Permit No...................................?`a--...... Issued_....... ! --------------
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
f�rr#i�utt#r laf fa�aut�tlittnr�e
THIS IS TO CERTIFY, That the Individual Sewage Dis osal System constructed ( ) or Repaired (
3 001,J4- G y L AInstaller
at......................................................................................................................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ----------- �.l---- 3..4 ............... dated ............. ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........�- ......... ....................................................
Inspector....---•---•-----••-------- ----- ..............