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HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF YARMOUTH Appliration for Disposal Works Tons#rixaian rrruttt Application is hereby made for a Permit to Construct ( ) or Repair oe<) an Individual Sewage Disposal System at: nn n P—s �. ..... - ---- •-- Loc ion - Address ---••• or t No. ............. B �� ow �S %!� L1�✓� t� �Aa..... Y% 1 I LLS ............................ Installer Address Type of Building Size Lot ............................ Sq. feet Dwelling — No. of Bedrooms .............. ......... Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures................................... ....................... . Design Flow .................. ��.........gallons per person per day. Total daily flow..............---.---....._ ................. gallons. Septic Tank — Liquid ca.pacity.e/ ..gallons Length ................ Width ................ Diameter................ Depth ................ Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area ...................sq. ft. Seepage Pit No ------------- /... Diameter......�v ...... Depth below inlet ....... .�1.._`...... 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...................•--.......................................-----------•------•----•---....------••----•--•------------•---•-•---..........---.........--•------....... •---•--•---•................•-•-•--•-------•---.................................._•-•-.T .....•---.......-----' ._�---......... .....-- ...... Nature Repairs or Alterations — Ans er when applicable.. ! l~�....... Cr ud _....... j............... i �v ... �....... �� ,�'` .f._.. c.'TC��'`y�-•---•--•.................................... 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 josued by tIpAord ealtL j Application Approved Application Disapproved for the following --...............................•--••------•----. -••-----••-........----....-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH Trriiftratr of Toutplittnrr THIS IS TO CERTIFY, Th -d the Individual Sewage Disposal System constructed ( ) or Repaired t� J�7ca"'7 11 vall at-•-----------.�........_e_................... has been installed in accordance with the provisions of TIT 5 U e State Sanitary Code a descr' P the application for Disposal Works Construction Permit No......��."' �.�.....-..... dated ......... r© ..�€?}......... THE ISSUA CE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUE S A GUARA TEE THE SYSTEM WIL SATISFACTORY. DATE............. I ........... - � ....................................... Inspector...._. ... -