HomeMy WebLinkAboutApp-Permit-ComplianceNof .... .......
THE BOARD AOF LTH OF
HEALTH S
TOWN OF YARMOUTH
Appliratiun for Disposal Works Tonsirur#inn 1rruti#
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
System.��..:t : u-. Cov `' .�............................ ..... " ' 3--------C.�c 57...----•...----------..........
- Loca ' ddress or Lot N
--.... ..�_�.��.....: 1 _N.._. .1. e................ c e T" ....----------•-....-----........._-----
L
Owner Address
--...�.. ..�.v..----------------------•------------------ ........ _Q� �. .. ..._._._.....
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms._r3..................................Expansion Attic ( ) Garbage Grinder Wr
Other —Type of Building ........ ............... No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures ..................................................................•---••--•---------------••---------------------..................---------...-----
...gallon
Design Flow...........................Nesper
per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capac_.gallons
Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No - --------Width ... Total Length ....................
Total leaching area ...................sq. ft.
Seepage Pit No ---------------------:..........
Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( )osing
tank ( )
PercolationTest Results
med--------------------------•--.........---•--..._...--•-•---------------_..
Date ........................................
Test Pit No. 1------------- -
per in
Depth of Test Pit ....................
Depth to ground water ........................
Test Pit No. 2...............per inc
Depth of Test Pit ....................
Depth to groundwater ........................
Descriptionof Soil -----------------------------------------------------------------•------------.-.....---------------------.......-...---------...---------------------------------------
.--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------•---••------------------•----------•--•----...........•---------- .......
Nature of --Repairs or Alterations —
-------------------------
Agreement: '
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 b the b and of health. p
Signed -- •. •. ..... ............. ....... .�.... �``.� ....
Application Approved By .......
... -• --- •................•--•-....... ---------------•----....---...._....._......._...--....... . __.........-------•-- --------
Date
Application Disapproved for
Permit No--------------- `�� Z'=--------- ------
---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
&rtifirate of Touttilianrr 1/1�_
THIS IS T - TIFY. That ,$e Individual Sewage Disposal System constructed ( ) or Repaired "
by....................... ��..L1.................................................................................................................... ...._......
Installe
at ... . ........... %... -........��V4G' �-----....------...........----------•-......._..
= �' `. G�
has been installed in accordance/ with the provisions of TIT 5 of The tate Sanitary Code s de cribe in the
application for Disposal Works Construction Permit No.____._ _^_ 2.. ..... dated ........ ..IZ— '�...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS�A GU NT T AT THE
SYSTEM WILL FUNCTION SATISFACTORY.
t l ..
DATE------------- --- --- - �... .... .............................. Inspector....=. -.:..'