HomeMy WebLinkAboutApp-Permit-ComplianceNo_., .... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fss_..... IS7
Appliratiun for Disposal Works Tonstrurtiun Errant
Application is hereby made for a Permit to Construct
System at: " )
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y(�
Ijqatio - �ddcrr 9
.... .. l........ 11.°.s"`..T .1 ................................
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Installer
) or Repair (_- aan Individual Sewage Disposal
-- -- -- or Lot No.
------------------------------------•--•-•...............•••--••--.............................
Ad
1....0 trl iM...
Address
Type of Building Size Lot ............................ Sq. f
Dwelling —No. of Bedrooms....... �..............................Expansion Attic ( ) Garbage Grinder (%
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Oth7_'_0
tures.-----••----•.........................•-•--....--••-•--•--...---.........----••-----•.---••-....... .----
Design Flow........ ..........................gallons per person per day. Total daily flow....... � n..................gallons.
Septic Tank — I.iquid' 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........................
Description of Soil ..........................................
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has Peef issued by the bo r f 1 alth. /
S' ed. .. .. .. .---•----------------------•.......
DI
Application Approved By ....... ................ �.............................• ---- •.-• -4 ........
Application Disapproved for the following reasons:...
Permit
e
.....................................
...... ••...........................
Issued......../ Date
..... ..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrttfiratr of ft omplittnrr
THIS IS TOLE TIS t the Incjr Sewage __!spoVOstem constructed ( ) or Repaired (--•-)
at...................... ------ .. ----•• - ... -kd............................
has been installed in accordance with the provisions of TIT of The State SanitaryCode M -C,
sribed n the
application for Disposal Works Construction Permit No......... �. ^G.................dated..._._.__ ,---�. .......--..
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BEC RUED A GUA ANT TH T THE
SYSTEM WILL FUNC ION S TT4IS ACTORY.
DATE............... ......! 7 _ .. _...._............ Inspector --....---.......... ........... ..........................
