HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Yorks Tonstrurtion Frrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
do Address or Lot No.
............. % ��.......A::..__..._......-------•-•-__.......---•-........................................................................................... ---•----------------•----•-----•--•--......----•------------•---•.............____.......
..--- Owner -----------------------•------•--•-----._.._Address
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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 ( )
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 ........................
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Descriptionof Soil----------------------------------------------------------------------------------------..............................................................................
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Natu of Rep irs or Alterations nswer when p likable____. ?...... 3!4.�_.... P��L_____.............
W�-'...... d�2....... ................................. ........... :..............
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 issued bythe b d of health.
Signed.-__ Signed. -__q..
Application Approved By...
Application Disapproved for the following reasons:
Permit No ............. 1_ ...... �._.- J.
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/ta ( ................. � --
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Date
Issued _............ - { -...............
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trtifirair of Tontpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (LK�'
by........................ A.%.G?.................................................................................. - .............._... -- --- ............
/ Inst ler
at. =fLt1 z...._._.4 r.�.ft1_ Q...........................................................................................
has been installed in accordance with the provisions of TIT 5 The State Sanitary Code as d seri d • the
application for Disposal Works Construction Permit No.___�5__ ___ _________________ dated_:..___.__.__ : ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. /
DATE ............ 1.. - /.-
...................................... Inspector_'---_._� . . ..... ----J-••- -- - --- ......