App-Permit-Compliance. IPA
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratinn for Disposal Works Tonstrudi orn rnmit
Application is hereby made for a Permit to Construct
System at:
-•--..... s_..couw7':._t_..%t....................
Locati Address
.............� .... --= 3 .......................................•..............
•- Own-
........ .' 'ez
n :....t. ---------------------------------
Installer .
Type of Building
) or Repair (4,/� an Individual Sewage Disposal
r NI
.....--�Q ;���i��
-.............................................
Address
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. I................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 ...................................................................................................
--
Nature of Repairs or Alterations — Answer when a licable r'�. ��' j...� _ .%�..'rr�
.._.a....xs,l Vit....-..
......................... .�1.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 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 b the rd of health.
Signed..... ...........................
i d�
% at
Application Approved B yt ...... : -• `��--•-----
Date
Application Disapproved f o the following reasons: .............................................................................................................. -
g �y z Date
Permit No..... Z......
...La ................................. Issue& ......... Y...l..c 1.......:............
Date
—— —-----,_... --- -- -- -, — -
x
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
f�rrtifutttp of fanut��ittnrr
THIS IS TO CERT Y, That the In vidual Sewage Disposal System constructed ( ) or Repaired
by.................................:n V C.... .•--...... _..................---....-•---...........---...._......:...............................---.........
_............. ---........... --------------------- — -
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 .......................................... A-1
THE ISSUANCE, OF THIS CERTIFICATE. SHALL NOT..EE..-CONSTRUE S"UA NTEE THAT THE
SYSTEM WIL FUNPTIO;N SATISFACTORY. :;1��,ar M1�; i,,a
DATE......... $.�.....�.��.. � �:..... .....:...... ........................ Inspector ..:---_.-------------•-....................................