HomeMy WebLinkAboutApp-Permit-Compliance1-1
No ........... -411/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fics............. L'�
Appliration for Disposal Works Tonstrurtiuit Frruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disppsal
System at: Gd7"7 / �'/
.6. .__y.. 9 . ..;. A. -
Type of Building
Dwelling —No. of Bedrooms_................................Expansion Attic
Other — Type of Building ............................ No. of persons .......................
Otherfixtures--------------------•---._..._..---•----------------...-----•-••--•---..._..----------
Size Lot ............................ Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' ca.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 ........................
Descriptionof Soil ............................................................................................
..------------------------------------------------------------------------- ------. ........................................
Natze of Repairs or Alterations — An aver when applicable�!% _-------- _.__ .__...:, ✓1_:..
Agreement : /I
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n iss_ e - by the board of health
-c'
Signed- ------- '. ..................................................
.... �-
Application Approved By._ _9___
.._...-•------- -----•
-•-_--------•---------------•---------------•-•---•• 6_:.' _- D°-t�`.q 1—
--- .Date
Application Disapproved foci tre follo7ling redsons___________________
_ Date
Permit No.. • a .......................... Issued......_.G.. ?--y---� Z .............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Intifiratr of T autpliaurr
THI IS TO CERTIFY, Ththe In vidual Sewage Disposal System constructed ( ) or Repaired (1�
by &- .....-----------------••---•-•.----
••---•--•----•-----------•--•-----••-••................. ..........
Installer
at........ ........... _ z' Y ��R
has been installed in accordance with the provisions TITLE 5 of The State nitary Code as described in the
application for Disposal Works Construction Permit _______________ dated__-.- C _--_l " q Z--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A 6�4ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--•-------•--•- ...... ...................... ... Inspect -------------•....------------•-•----•- ---------------...._ .................