HomeMy WebLinkAboutApp-Permit-ComplianceNo..1. Fps.
THE COMMONWEALTH OF MASSACHUSETTS ' o
BOARD OF HEALTH 1,
TOWN OF YARMOUTH
Appliration for Disposal Works Tons irrn rrnti# OT=-13/AW_ 68
Applicatio�is hereby made for a Permit to Construct ( ) or Repair ()an Individual Sewage Disposal
Installer
Type of Building
Dwelling —No. of Bedrooms .............................. ..............Expansion Attic
Other — Type of Building ............................ No. of persons .......................
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. 1 .............. 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.....--.................
Garbage Grinder
----- Showers ( ) — Cafeteria ( )
Description of
----••••-•-----------------------------------------------•--------....--------------------PP •--------•--�------. = - -•--•-.... . =....................................
N"reRepairs or ations—Answer when a livable__ JU.....::_.` -5 ... �..��..U�...'..............
._...---- . .................... .-•---......•••-•-----•.............•-----••-------•-----------....-----•-- •----------------•-----..............----
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee'ue�t by the board_ofHealth.
Signed.
Application Approved By
Application Disapproved for the following reasons:.........
...................•-•--•--•------•-•-------•---•-............-------••-...
Permit No.... �.....-------••-•--•--•_..._
.....�.....
Iiat� _ ��
.................................... ..
Date
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Issued.............®.,J- ......
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrlifirtt#r of f�untpliatty
T fS TO CEIFY� Thatae Ind victual Slewage Disposal System constructed ( ) or Repaired
has been installed in accordance with the provisions of TI5 of Stai(e Sanitary Code as de rib the
application for Disposal Works Construction Permit No.. --.w_... ....._--- dated --- .._��.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUED AS VARA I EE T T THE
SYSTEM WILL FU CTION SATISFACTORY.
DATE............... l� - G ----------------------------- Inspector-- --•-•------------------------------- ----- .._ --------