HomeMy WebLinkAboutApp-Permit-ComplianceNo. .... .1 Faa,l... „..../...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tons rartion 1rrutit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
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Owner ••-.• -Address
a ...........�...... 1.. .. .................................................. ........ j��1....rN.:...Installer W..... ....._..._..................
ddress
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ............. -.............................
W Design Flow............................................gallons per person per day. Total daily flow ......................._.._.................gallons.
WSeptic Tank — Liquid ca.pacity............gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width-................... Total Length.................... Total leaching area .................... sq. ft.
3 Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area ................. .sq. ft.
.z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
0" Test Pit No. I................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 ........................
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0 Description of Soil ............. ......
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Nature of .4 rs or A�etrations — Answer when a ica 1 - ✓0.6._........ � ........... _
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Agreement:
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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 byte boar4f health.
Signed.
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to
Application Approved By
Date
Application Disapproved for'06ollow' reatso :..............................................••---------............_....._............._......................
Date
...............Permit No...... --- •�•--1 -...---•------•----...._...........------.........._...Issued.... 1_� .�.✓`�%..-.•-------......
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D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrf firate of Toutpliana
THIS IS T`TIF�', T th ndividual Sewage Disposal System constructed
by ................ ................. /.1......... ...............--- ..........................................................
.....
.Installer
) or Repaired (L�
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Coda as described in the
application for Disposal Works Construction Permit No.._..__. � : � . hi
..... � dated._....: �..... f.�....�,':=. .............
THE ISSUANCE OF THIS CERTIFICATE. SHALL NO E� Com% RU DASA UAR TE AT THE
SYSTEM WILL FU CT ON SATI ACTORY.
DATE....................r. C- `--. r .......---. Inspector `-`---=-----•- -- . --b.----------.---------------