HomeMy WebLinkAboutApp-Permit-Compliance (COC not issued)THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fast t)...__...._....�
Appl ration for Disposal Works Tonutrnttion Vantit
Application is hereby made for a Permit to Construct ( ) or Repair (v, -)an Individual Sewage Disposal
System at:
�L.......... ............. ............
oration - Address
Address
......:..��:....`.�.U1'!`....�-!ice............................ ........
......... .........F-6.C1.C.�L.!!.K-C�
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...........................................gall s p
erson per day. Total daily flow ............................................ gallons.
Septic Tank—Liquid capaci ............gallons
L gth ---------------- Width................ Diameter................ Depth ...........
Disposal Trench — No .................... Width.................
Total Length.................... Total leaching area ...................sq. ft.
Seepage Pit No .................... Diameter..................
epth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( D ing
tank ( )
Percolation Test Results Performe y..................---•----••------•--------..............................
Date ........................................
Test Pit No. I ................ inutes r 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 .......... _............................................................................ ............................................................................. ...
of Repairs. or
Agreement: bT t"t 4-3 3 I1 orx '1 "c - - 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 been issued by the rd o lth.
Signe — �%�
........................ /. ........../.. ...
Date
Application Approved By .......... .... •........ ----------•--............................................... ..../.�? 7-1.70
D tc
Application Disapproved for the full ing r asons:----------........__.......•------------------------------------------------.........................
Date
PermitNo ......................................................... Issued .......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtif rttte of Tomplitturr
THIS IS TO G Y, That thedividual Sewage Disposal System constructed ( ) or Repaired
by................................ C.? ..........------------------.........................................................---•--•............................
........... .-•------•-•-•------••....................•--------------------............................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
rl.t TL` T - i