HomeMy WebLinkAboutApp-Permit-ComplianceF. Q - � � 1 `J\�(L � tee. • � ` V
No.... ` ... ff FEE............. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonsirur#inn thrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: VL
....---••---. � ��.... . ... :................... ................... --------•----------•-----------------
--. - LL atioon - ddress -.-- or. Lot No.
......... LeC:.t✓.� ................................. ...............---...-^---............................
Own Addr
Installer Address
Typ of Building 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 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 ....................................................................
•----------•-------------------------------------------------------•-------•------.................-- ---•-- -- •--- ....... ......
Nature of Repairs or Alterations — Answer when applicable__._ _._
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE4 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ssued by he oard healt
Si
t D
Application Approved ............ .......-----------------------------------------
, - --% 0
Zate
Application Disapproved for the following reasons: .......... ................................................................. ......... ...................... .
..................................................... --•---•-----........---•----•........--••-••-•---....----••--•--------................--------------...........----•--•----••-•-••--•---••-
q
Permit No. - -r - ...... Issued... �� ..1........................ j
------------------------- ------•---------------------- — — — — — -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(9rrfifiratr of Tonttrlittnrr
THI E
C R IFY, That the Individu l S � e Disposal System constructed (1 or Repaired 0
by......, :...� � :.-......- � ---•--------------••----------.------------•-.-------- --------------•--------...._
--
i A Installer
at.......... i---- -------- ..+:+==--............. .r+ .-.-----------------------------------
has been installed in accordance with the provisions of TI 5 of_ The State Sanitary Co . as scri ed in the
application for Disposal Works Construction Permit No...__ .._ . - The
dated ....... ... ...................
; --
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT . CONSTRUED A GU A TEE THAT THE
SYSTEM WILL UNdTIO SATISFACTORY. ``'`��
DATE.........._- �........ Inspector---- •-•--•----•- ......... = 1-....... ._......