HomeMy WebLinkAboutApp-Permit-ComplianceNo... .�.-..�1 Fss`-•Ja��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
4 '
Applutt#ion for Disposal Works Tons ' n lirrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
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Installer Address
Type of Building Size Lot ............................ Sq. feet
4 Dwelling — No. of Bedrooms................��.........................Expansion Attic ( ) Garbage Grinder ( ) yes
4 Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
4 Other fixtures
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
4 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................eminutes per inch Depth of Test Pit.................... Depth to ground water........................
s Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water........................
Description of Soil .................................
• of Repairs or Alterations Answer when
,.:...................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIS 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i�W b)) !�e bo4d of health.
Application Approved By....
Application Disapproved for
•--- ..
Date
q �p� Date
Permit No .......... 1....`�............................'.. Issued. ........... .. lam:
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trriiitrate of Toutpitaurr
THIS IS C-ERTIFY That the Ind, idual Sew. a Disn- sal System constructed
by....----....� s .....� L.... , -- ®: ". ....f. ?.. �............... ........:
or Repaired (+�)
has been installed 'in acroance with the provisions of TIT 5 of he gate Sanitary Code as descr d in the
application for Disposal Vorks Construction Permit No......49.7 "''y��.......... dated .......... ,1%.:r7 _---9.-•••-.---.--
THE ISSUA�CE OF THIS CERTIFICATE. SHALL NOT BE CONSTR D A GUARANTEE THAT THE
SYSTEM WILL "NC
ATISFACTORY.
DATE..............!!......4��a...----..............----........--- Inspector...... ............_ ..... (� ......... ......----....................