HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
AVVIiration for Disposal Warkii Tonstrnrtiort Termi#
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
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........------.--•--.....----------------------------•---------:------------.............. ..(?.�---� 75.;V X. ........ ......
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms....................................Expansion Attic ( ) Garbage Grinder ( ) A10
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........................
Descriptionof Soil ............................. .......... ................. ............. .... .............................................. .................................................
_.............. .--- . -- .... ..... ----.....
... ... ........ ...................
....>>........... - - - .... n
Nature of Repairs or Alterations Answer when applicable...l..D...�..0 S.........S..._/..1>.LE...0Q'k._............
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Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL% 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i sued by the board of health. }�
_Signed..- ......- �.......-1........
-... y. .. .�y
Application Approved By �..�.� '-�,..
..... .............................
.......................... _Dat c
Application Disapproved for the following reasons :............................ __
Da�
c�
Permit No ...... 2&..` :. a....... .... Issued ....... .. c%.... ..1......................
Date
.______________-_—__----_—._ ____________ —__
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tertifirate of Toutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
has been installed in accordance with the provisions of TITLE $ of„The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.....5.` :%�............ dated ....... t ..... 212 .... ..p' ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ...5..... -` -. Inspector.... .: '......! ! .), €:,.