HomeMy WebLinkAboutApp-Permit-ComplianceNo...Cf...................`^ Fps . ..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
S
Appliration for Disposal Works Tonntrur#inn jkrmit
Application is hereby made for a-Zermil to Construct ( ) or Repair ( ) an Individual Sewage Disposal
o System at: ` l- _ 8
..._._.... •• -
bocati ddres ---• or Lot No.
9/1 10wner- Address
Installir Address
Type of Building Size Lodljk o..._..._..Sq. feet
Dwelling —No. of Bedrooms ... _....... 4 ............... _........... Expansion Attic (fio) Garbage Grinder
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Othertures-----------------------------------------------------.-----•---------••--••-••----•-••---• ......_.........-- •......._..-•-----.._....-•---•--•
Design Flow.._...__._ ! ......................gallons per person per day. Total daily flow ......... V%)..__.______..___.___._..__gallons.
Septic Tank — Liquid' ca.pacity.l_OO_O.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 (rV) 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
-----------------•----------•--------------------------•-•----------------------._._._..............----------------------------------•---...--•--.....--•--------...-----------•-••--....•-----•-------
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 TITLZ 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been 'ssued by the boa of health.
Signed.... -- •---_ ._.._�------- -------- - - - -------------------•---.. _ . .?s_._...___..
Application Approved By.. _
U e
.. . _ ----- -----------•- ---•--- -•---•----...... _.._.��....__� •Date -•-•---•-----
Application Disapproved for the following reasons_ __________________________________________________________________________________________________________
..--•••---------------------------------------------------------------------------------•...----------------•---•--•---•-•----•---•----• • •--••-•-----=--------•...................
Permit No.........
- -� � 7C. ............................ Issued.........7- ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
f�rr#ifirtt#le of f�nnt�rlittnrr
THIS IS TO qERTIFY, That,th Individual Sewage Disposal System constructed �) or Repaired ( )
by------------------------------w>. cl ....._ :... — z�Y!� .d ; --------------•--------- -----------------........ --------- --
Install h `
at........................... r,. �?__...Yt ..... - l C` f_'J .?:._.:_._.._ ...:
has been installed in accordancith the provisions of TITLE_ 5 of The State Sanitary Coe as described in the
application for Disposal Works Construction Permit No._S. _��_______________ dated__..!_�r�_z,1_'�__.____..._.__.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY
DATE................ ='L--- f - ------------------------------•---- Inspector --- - --•........ ----•-- ...... ....- •------••----