HomeMy WebLinkAboutApp-Permit-ComplianceNo. q2-:370
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Applutt#tun for Disposal Works Tonstrixrttun trrutit
Application is hereby made for a Permit to Construct (-elor Repair ( ) an Individual Sewage Disposal
System at - O _
- n A Location - Address ,- or Lot No.
Owner .7...... .: ...�..:.........•-• ...............................Address..................--•-•----...........---..
.... ... _{......$ ........e.tz f. x- ..• _ ................... ..... ............c -...... ...................................................
.... .
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling No. of Bedroo s........... ................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ...........................: ldo. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures .__...._.._...,.. .------••••-•••....
....... ........
Design Flow ............................................ gallons per person per day. Total dam flow ............................................ gallons.
Septic Tank — Liquid capacity/afeJ .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 ........................
Descriptionof Soil ..........................................................................................
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..
Nature of Repairs or Alterations — Answer when applicable......... fiery:...................................../UIJo ¢
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Agreement: •V)
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI.1 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be is ued by the hoard of health.
Signed.........
Application Approved By ............. . -----
Z
Application Disapproved for the following reasons:
C1_2_)
Permit No.........- .�.zJ...�.
..�... �...... .......
.... �..-:.5`...G....
Date
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jq_,��_ _ZDate
Issue...--• ................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#if irate of Tomplittnrr
THIS IS T -CPTA
, That Individual Sewage Disposal S7stem constructed ( ) or Repaired (a.�}°•
bY......................................... ®........... ...... A.............
Installer ► - — ..�...... .�.........._.._..,...............................................
has been installed in accordance with the provisions of TITLE--- 5 of he State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__..,! .:_..._� ��.. dated..... 0._ .. . .. ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA G ARANTEE THA
SYSTEM WILL FUNCTION SATISFACTORY.�_, ��{ .
DATE......_........... ........................ ................. Inspector.... 1. ....-... —..-- ........`r' ...............................................