HomeMy WebLinkAboutApp-Permit-ComplianceNo.
THE COMMONWEALTH OF MASSACHUSETTS Ilk
BOARD OF HEALTH
TOWN OF YARMOUTH
Appltration for 11isposal Murks Tonstrttr#ion 1hrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( Vl'**an Individual Sewage Disposal
,.System at:
LotionAddress 10 0
....---.---. ,�...... -................................................................. ........
ne� / AdIr
ess
Installer Address
Type of Building Size Lot............................ Sq. feet
aDwelling—No. of Bedrooms......... ...................................Expansion Attic ( ) Garbage Grinder ( ) A10
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
d Other fixtures
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid' capacity............gallons Length................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No..................... Width .................... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank( )
1--fPercolation 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 ........................
DDescription of Soil........................................................................•----•--•-•-••------••---.................-----.....................................---.........
---.....--•--......--•-••............................
W'..............••--------........._........----...........--•---------.....-•--••-•-••••....---••------...•------••••....................----..
U
Nature of Repairs or Alterations Answer when applicable.../ ..._.Z ....... ......
..........r'1� �.._ � S _d 7{ @......................................................................................................
Agreem t
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.
Si�° ...................... 3
Application Approved By-.. --- ..... ............
Date
Application Disapproved f the following reasons:................ .............•---•----•---•-•--•-•--•----•---......--------------••...--•-•-•-------..........
........................................•----------.................................---................................---••------•-•----....---...-•-----•-•----.......------............--•-•••---.........
Permit No....% :T............................. Issued ........... ��......<...:�..
Date
Permit
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(irrtif irtar of faoutplutnrr •�
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( V4
by..... C �:1. C....... ....................................---.............................................._..._
Installgg
at....................................................................• .... ..'. .............-----•.
has been installed in accordance with the provisions 6f TITLE 5 of The State Sanitary
Code as described in the
application for Disposal Works Construction Permit No.... . .. ............ dated ... .... =1 .1 .................
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GU ANTEE THAT THE
SYSTEM WILL UNC 10 SATISFACTORY. � �, �
DATE..................:�,...�...�. ..---........._.............. Inspector.....]..... , ......................