HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS �(\
BOARD OF HEALTH 11i�
TOWN OF YARMOUTH
Appliration for Bispasal Works Tonstrurtion Flexmit
Application is hereby made for a Permit to Construct ( ) or Repair (><) an Individual Sewage Disposal
. System at:
_5,g4Xga ress ('/ ,-�� n � or Iof
Owne Address
O.'Lr !J L�VrLh1 S �i,(�-IL , d1/1 [ trS
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Installer A dress
Type of Building. Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms..................-�r .......__.__......Expansion Attic ( ) Garbage Grinder
Other Type of Building ............................ No. of persons ----------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures -----------------------------------------------------------•----------------•-----•-----------------------------•------------------------------------
Design Flow ................ .................. gallons per person per day. Total daily flow.._.. � Q_ ----------------------- gallons.
Septic Tank —Liquid* capacity- l<gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No. ........ /-......... Width ...... :_------- Total Length --_.�.faX4 Total leaching area ...................sq. ft.
Seepage Pit No--------------------- Diameter .................... Depth below inlet...1! _.._.. 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 --------------•---------------------------------------.---•-_---------------------
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UNa of Repairs or Alterations — Answer when applicable... ........._--`'..�...._ l!J� 4 7'�_..s..?!/J^rb
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT12 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 ed y the oa of health.
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Application Approved BY----•;�e`
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..........
Date
Application Disapproved for followingans-------------------•--------------------.....-----•-•---•----------••---•------------•--••-•-•----•-•-••-......
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Permit No..--••••-- `-� - `s= ---... Issued.......... � �'�....Date......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Erx#ifiratr of wiJutplittnrr
THIS IS TO CERTIFY, That,the Individual Sewage Disposal System constructed ( ) or Repaired (�L)
by .............lJ /�--.`� Lr3 j 7=1d1.�) 2 �.1
.......--•-•-••-•••.-....... - -- ................ ....--•-•-- ...........•---•- ........... ................................
Installer
at....----•-• ..............................•-- eeL1 "� `
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has been installed in accordance with the provisions of TIT 5 The State Sanitary Code a cl scrib In the
application for Disposal Works Construction Permit No ....................................... dated ........ _/ . �� ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA A TEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ;
�.e..........�....... .DATE...........� ector------. i