HomeMy WebLinkAboutApp-Permit-ComplianceZ
a�Z
No. Lce 1 Fs
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tons#rur#ion jirrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Van Individual Sewage Disposal
an at: . g AAA�
O ner
Installer ' Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms...........s.........................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........................
Descriptionof Soil ........................................................................................
•----•-------------------------------------------------------•---......_..------------.........---------...--------------------.........................--•- •,.............._...
Nature of Repairs or Alterations — Answer when a plicable---, --'---...... .. �1 �.� ..... V - -�
` - ......�......................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System In accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been is�d by the board of health.,
Application Approved By
Application Disapproved f
•-----------------------------
Permit No...........,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Err#if iratr of Toutplinurr
THIS aTQ _CERTWY, That the Individual,/Sew�ge Disposal System constructed ( ) �r Repaired
3
------------------------
Installe
at .......... �.... � .... -� ,u
......
has been installed in accordan a with the provisions of TIT of The t to Sanitary Code a describe in the
application for Disposal Works Construction Permit No......_.V.�."�}g.�.... dated_ ........ Z.....°Z��_. _��....
THE ISSUANC OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AtA. GUAR N rEF TI AT THE
SYSTEM WILL N TJON SATISFACTORY. ` ,?
DATE.............. ' .� �f ......................................... Inspector - - .... ...... ...................................
f'