HomeMy WebLinkAboutApp-Permit-Compliance¢'No.---1� e!J✓% Fps_ ="�l7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
ApplutttiOn for Disposal Works TonstrurtiOn rnmit
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Application is hereby made for a Permit to Construct ( ) or Repair (V-5"'an Individual Sewage Disposal
Type of Building 3JIZe i.,of ............................aq. ieer
Dwelling — No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
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. l ................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 Soil.. !-•`-TL L - i i............................................................•..
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------- ------ --- ---
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Nature of Repairs or Alterations — Answer when applicable---
..., P .............................................................................."----•---•--.............
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 is ed_V the board o ie thn
Signed.
Application Approved By... (
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Application Disapproved for the following
Permit
.... 3
............................................. �� `..........
Date
.........................•--------------...............----------.
...............•-•-•-/--............--•--........................
Date
Issued......-- 5 .....lc ..--•-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tnrtif iratr of TOMptittnrr
THI IS TO CE TIFY, T the I ivi Sewage Disposal System constructed ( ) or Repaired (�
by ..... .S .., % ..%(1.._. .................................. --
......................._.................................
. nstall
has been installed in accordance with the provisions of TITLE 5 of he State S .nitary Code as des i1bed the
application for Disposal Works Construction Permit No... d ted.... �� - -
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOL BES. NSTRUE GUA TE THAT THE
SYSTEM WIL RUNCTI SATISFACTORY.
DATE............... `tY�\`- -\ .......................................... Inspector...... ....._...� �..y. ......................