HomeMy WebLinkAboutApp-Permit-ComplianceNo.. J ..._..---•- � �17l 0�'7/-
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• �. THE COMMA H OF A SAC'HUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonu#rnr#ion f umijt
Application is hereby made for a Permit to Construct ( ) or Repair >40 an Individual Sewage Disposal
System at: Lvr " � O 3
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.Locatio s
- ddres� or- ot
..... �P ...... d . s �3$ -4�-r�s Lr- Cy � i....• ...................
IX/A n 67-f l % 1 1 ar/
p� 117
Installer Address
6 Type of Building ? Size Lot ............................ Sq. feet
U Dwelling —No. of Bedrooms .................................... _....... Expansion Attic ( ) Garbage Grinder (/VjC3
'4 Other — Type of Building No. of persons ............................ Showers — Cafeteria
Other fixtures . -------------------------
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W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic 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 ( )
Percolation Test Results Performed by .......................................... _............................... Date ........................................
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
W Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
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0 Description of Soil ........................................................................................................................................................................
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Nature
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Nature f Re airs or Alterations — nswer when app_jica,ble_.....�...........................................�....lr�z...............
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL.I. 5 of the State Sanitary Code T and rsigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss y ar o .
Signed - - ----------- • ..--•-------...... ...................................
D� ..
Application Approved By.. ........ . 3 VPS
Date
Application Disapproved for the following reasons: ............................................................................................................
:.... -._
Permit No.---.. 6 . ._ G ...... ...............
Date
...........................
— Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH Ocl
TOWN of YARMOUTH
(Irrfifiratr of Tong haurr
THIS IS TO CERTIFY, Tthe Individual Sewage Disposal System constructed ( ) or Repaired
by --------------- 662 n....�F%27 e:2......:. ......................---------------
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.. - - ...._.... -- ....._............_
b Installer
at...... -3.9 ----- LTcq��.. �l._ - �.:.`¢¢¢/../---------------------------
has been installed in accordance with the provisions of TITLE_ 5 of T e State Sanitary Code as described in the
application for Disposal Works Construction Permit No.-_ `?.5 ............. dated..... ).3.b.5�..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ................•. -••-------...._... p.`/G1�..._�
.........._ Inspector... ---• •- � �/ .......
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