HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Dhaposal Marks Ton,s#rnrtion Fermi#
Application is hereby made for a Permit to Construct ( ) or Repair ( O an Individual Sewage Disposal
System at: MwC(,r 3Js
�0..._NQ . ...--.. �: �:_T3 ' ---------------------- -----...................... -.............
�, •- Location - Address1� orLot No. ------------------------------------------- -------------------------------------------- - ...............................................
sj �' , / Owner ( �JAddress `
-.i�`.i�r_Yt=ttul4`:...--1=.,.�sZ... GAs:, Q...-..�-c!�'�..-- -�X�---`-----\C�?�4--...1 :.:. U.!'.t. t--..2.:.-..i..7.a.:•(�,,��
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling — No. of Bedrooms......:...............................Expansion Attic (
Other—Type of Building ---------------------------- No. of persons .......................
Otherfixtures---------------------------------------------------------------------------........
Garbage Grinder (Nq
Showers ( ) — Cafeteria ( )
Design Flow --------------------------------------------gallons per person per day. Total daily flow ........................................... -gallons.
Septic Tank—Liquid capacity.(--4?GU-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. I................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
of Repairs or Alterations —
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has keen issu chi7h he -board- of health.
Application Approved By ----.-.G/-..` 5
Application Disapproved for the following reasons:
..I.I•`% 3-
?')
--.----.---�.-.2.....--.---_...-.
Date
Date
PermitNo.... -�_`........................•--..... Issued ........... _ v- -_-...........
Date
---------------------------------------------------------
THE
_ _________ _______________________________THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(nerrifirab of Tantphatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
cz^f .: t C f. c......................................................................................................
---------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
M t"'
- ................. dated.....!..::.... '..:-.:'....-.
application for Disposal Works Construction Permit .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
7
DATE..............................................
... :::.. '' r....... – Inspector ......:.. 1 r