HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiou for Disposal Works Tottstradion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (,,Kan Individual Sewage Disposal
System at:
Locatio Add r s or Lot No
0 Are
.......---- - -° `./- L i
Installer 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 ( )
Other fixtures......................................................
.......•..................................................................*--------------------*-----. -----
.---------------------------------------
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. 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........................
......................................................---•--•1---•-----•------------- - --------- 41 ---------------------------------------------
Description of Soil .................... .1. �'�?...--�x_tc4►!
----------------------------------------------------------------------------------•--------------------...........------------.
Nature of Repairs or, Alterations —Answer when applicable .... 1._C'9.L4:J
Agreement 4`�'r'��"—�
The undersigned agrees install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 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 koarcLoi healyh .�
Application Approve
Application Disappro ,
Dale
Permit No ....... 2
- - ... ................... Issued.... s. ... --. .....--•------ -._
Date
0
THIS IS TO CER
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Ta ifiratr of Tomplittrtrr
That the Individual Sewa5e Disposal System constructed ( ) or Repaired ( �
li I al cam-- .1_ _
staller
(/<.J if`.+�: 1/ ... Ing( ....c,,,/ t� {J..... �;
at-••• ....... .............•------------� �.jj -
has been installed in accordance with the provisions of TIT 5 of he State Sanitary le �scr.iiin the
application for Disposal Works Construction Permit No date- ..r -
THE ISSUANCE OF THIS 10ERTIFICATE SHALL BE CONSTR D GAA TEE THAT THE
SYSTEM W-114 FUNCTIOWSATISFACTORY.
DATE...-................}:..._?--•-•---..............................