HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -�
TOWN OF YARMOUTH
Applirtttion for Dispalittl Works Tonstrurtion Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ((/) an Individual Sewage Disposal
System at: p
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�� ti�Address ��7 p o. Lot No
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.............__••____......-............................... ........ ..........._... .... ...............
........................................................................
Owner Address
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Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedro s ..... ..................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Buildii} ......... No. of persons ............. __........... Showers ( ) — Cafeteria ( )
Other fixtures 1..---------------------------------------------------- -
Design Flow .......................................... gallons p person per day. Total daily flow. ..................... ...................... gallons.
Septic Tank—Liquid capacit ........... allons ength................ Width ................ Diameter................ Depth ..............
Disposal Trench — No ................... idth--- ................ Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Dia er.......... .......... 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
D
Answer when
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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 been issued by the board of health.
Application Approved
Application Disapproved for the following
Permit No....... w .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Dam
q 1 Dam
TOWN of YARMOUTH
(Irrtifirttte of Tomplittnrr �/
THIS IS TO,CE-�TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired W )
by................................ J---Jlie2......�-.<?................... ..........................................................................................................
Installer
at. ..... L 3 d ....... ........... -i .......1//I !? ....... - ....
...............................................................................
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...." `.:...c_L.................. ............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION /SATISFACTORY. /
DATE.......................:::.�:.F..`.-:d'1.............................. Inspactor..)� ).....