HomeMy WebLinkAboutApp-Permit-ComplianceNo .... r JV �
....... .
THE COMMONWEALTH OF
HEALTH
S
BOARD
OF
TOWN OF YARMOUTH
Appliratiun for Disposal Works Tonsiruriiun f amii
Application is hereby made for a Permit to Construct ( ) or Repair (t-�an Individual Sewage Disposal
System at
C��" I
Lo on - Ad ress or Lot No.
ally
OwnerAddress --------------•--------------.-----
Installer Address
Type of Building•� Size Lot ............................ Sq. feet
aDwelling—No. of Bedrooms........ �?...............................Expansion Attic ( ) Garbage Grinder
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria
GaOther fixtures ...................•-------------------------•---- ......
WDesign Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid ca.pacity............gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z 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........................
Ra'
.......... -----------------•-----.....----------------•-----------------------......-----------------•-•---------........-•---•--------------------------...
0 Description of Soil ...................................................................................................................................
...................... --------......--------------------•---•----------------------------•---------------------------------------------------•.......--•-•-•-------........ ;----........
Nature of Repairs or Alterations—Answer when applicable. -D.15 -11._....1-_L±. _Il}710......
Sju�t� ----------------------------------•-------........_....----------.......-----•---.......-----------•---
Ament :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu d b herd of health. y
Signed. .••-•----••----•-----•--••••.- ... ....`��o�o?....��. [/
f Date `
Application Approved By...... t...._...-• . --- -----• ------ --- --..Ll..:' 3
Date
Application Disapproved for the following reasons: .........................................................................................................._
Permit No ........ .7...a�.`'.:/..:1...-<--------------- --__ Issued- ............ f/..� ......1................
Date
-----------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifirair of fanntpliattrr
THIS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (I-)-
by-------------------- ........................................... /.. ; ...........
/a In r Installer
has been installed in accordance with the provisions of TI 5 f h�j State Sanitary Code��??s es rib i he
application for Disposal Works Construction Permit No.... ... � _ {•--....... dated ...................... .:.... .....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION ATISFACTORY.
- -%/
DATE .............. .....� - • ....._.. •- - - ---- Inspector. = ..............