HomeMy WebLinkAboutApp-Permit-ComplianceNo._.9.�-�
THE COMMONWEALTH OF MASSACHUSETTS
. BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrudiun Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (j%�an Individual Sewage Disposal
System at:
:�:.. ...................
-Lo ddres
JS �Y•✓!•/ FJ'. •• R
.................
Installer
T of Building
o Lot No.
Address
ype
Size Lot ............................Sq. feet
Dwelling — No. 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 arm ................. 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 ........................................................................................................................................................................
W
. ...._-----••-----•---•.._......---•-..._...-_.-•--------•-•---•---•.....................•---.....----•---•---•-•------------•---•-----•• --- _--
UNature of Repairs or Alterations — Answer when applicable_.._ z ___ aZ ��� f r91 1 ............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I'1L 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed - -�`
g.�.
..� .. Application Approved BY--•--- --
.... -•...............•-•--------•----••-•••......-•-•-••---•---•------• ........................................
go n:Date
Application Disapproved for e folls.....................
1
— S
PermitNo. ---•--•--.I .................... ..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
1 Date
(anxtifiratr of Tomphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by......... e!2- ..---•----------------•--------........................................--•---.................................
Installer /
at.......... &.... .r° .........
has been installed in accordance with the provisions of TIT o The State Sanitary i as e, ibed in the
application for Disposal Works Construction Permit No ---- _-V................ dated_... ,, _..��1..`_-'.l __._...............
THE ISS ANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED GUARMTSE THAT THE
SYSTEM W�L �61•C IO SATISFACTORY.�—
DATE... .. ........:....... ........................................ Inspector,..:...
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