HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appltratiun for Disposal Works Tonstrnrtion 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair (-,)—wT'1ndividual Sewage Disposal
System at: •r- /l2 2-
............
............ ........... -------------------== _ v _w. , :`�.�,,.... .....Y -
oeation - Add ess or Lot No. -
............. o t......_�r .. .......................... ` :- ------._......-----.........................--
OwnerAdd ess t
............................. .............V.JoA, ..1 5 �.�,.
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 _....... 5;�67�----------------------- gallons per person per day. Total daily flow-_---_ ..................gallons.
Septic Tank -- Liquid ca.pacity_Lt50gallons Length---- X--------- Width -...-f ........ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..... I--------------- Diameter.... -4-A_0 v4Hepth below inlet ...U.(......... 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 ........................
Description of
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4# Repairs or Alterations — Answer when applicable
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 bx the board of h th.
Signe J��.s�
------ ---- ------------------- ----
Signe.._,7_�
Approved By ..... .. ___ . .. y.. ' Z�....
Date
Application Disapproved for the f owing reasons: ........................
.......................... -.. ..... '..Date ..............
I
Permit No.- - - .. - .............._.... Issued.--.- �?- - .._k ................
Date
THE COMMONWEALTH: OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trdifiratr of Tomplittnrr
THIS IS TO CERTIFY, That the Individual
by
Disposal System constructed ( ) or Repaired ( L._.. .....................
......................................•.--••••---------•---•-...........................
has been installed in accordance with therovisions of TI f The State SanitaryCo a as
application for Disposal Works Construction Permit No ... .-..•............... dated ...... . .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A G
SYSTEMA WI U Ti0m, SATISFACTORY
DATE ............ - y ...... ........ Inspector .....
in the
s-' ---------
THAT THE