HomeMy WebLinkAboutApp-Permit-Complianceq2.-Z?6
No... ............. -.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
, pplirtt#ion for Disposal Works Tonsixnr#inn ' Frani#
Application is hereby made for a Permit to Construct ( ) or Repair (4. �)an Individual Sewage Disposal
System at:
,n dd e .
•... .0 ..
Owner '
Address
-- ....:.--------------------------------------r'A� ••--.......---------------••----------..........
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 ( )
Otherfixtures------------------------------------------------------.--..........-•--•••--•------••-•------•--•-•-.............-•---........----....................
Design Flow --------------------------------------------gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ea.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 ........................
Description of Soil ...................................
Nature of Repairs or Alterations — Answer w en applicable ct j.- Z7.. i --'�- --•-•--......
.. � _---••.--•-•----.•...... .................•.--.•-•--.----------.....
Agreement: /
The undersigned agrees to install the aforedescribed Individual Sewage Disposo 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 issuedhe bo d of health.
Signed-------- ------•-•------------------------------------•----
Application Approved By.__ .__
Date
Application Disapproved f oUhe following reasons:
----------------------•--------------•-------------•-----•-•------------•------------•-----•._.I_..--•-••--•---•--•--•-•-----•--•-•------••-•-•-••---...--------...-••-•---------.......
4 Date
Permit No.------. - -.......... _.... Issued------ ....................... . `..._:..........._
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH`l
. Cnr�tifutt�.e of fauut�littntr ._
THIS IS TO CERTfFy,That th�Ind* r'duaI Sewage Disposal System constructed ( ) or Repaired (!/j
by........ .................•-- ._. Q.S.�......... S.�t.?..--•-- ...............................---...........-•----•---.......... .......---
at......... __._�.u..c. 1 �..._. ... 4�".al..Z .. /
has been installed in accordance with the provisions of'TITof The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..:___:_�_=__�,�.(- �.. dated ......_=... Z...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE -6 AS A GU,ARANT E ' HA THE
SYSTEM WIL FUNCTION ,$ TIFACTORY.
1
,S �
DATE ............... f l ... Inspector.......................