HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1....:5....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fizz Z.9
Appliration for Elispasal Works Tome rur#ion Prrtnit
Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
systema j Rile—)66t,�
Location -Add ss or Lot No.
— .--•---------...
..... .._ ...
Own Address
•�
In aller Address
iype of Building Size Lot ............................Sq. feet
DwellingiNo. 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. 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..- ._.----.
. r ---....................._....._...........
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Nature 'pairsGAl eratiou - Ans ' er plicable( L
1. 1 ------------- ...............................
Agreement:
>�OD t io s i7>•`/E'
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 been
yissued by tPe b�ardhealth.
Application Approved By
`gate-�-
...............................................
Date
Application Disapproved for the following reasons-------------------------�f---------------
1--.-.--_-----.-.--....-
.....----•.....•-----•----------•--•-.......-•-•--•••----•---•-•---------------•-----------•-•-•----•--••------------•-•----••-------------•-------•-------
PermitNo.... .. K ...............................................� S
Date
Issued....... .........................
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifirat a of Toutplittna
TIJIS
JS TQ,CERTIFY, That, the Individual Sewage Disposal System constructed ( ) or Repaired
t
/ 2"
_----•--- B- -------------•-•-•---------•--------------------------------
InstaXtr
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.---- ----------_----- dated ----_----..2 ....----........_......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector..------......----------------------------------------------------------------.....-