HomeMy WebLinkAboutApp-Permit-ComplianceE2
No. 2. 12
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion 1hrmit
Application is hereby made for a Permit to Construct or Repair ( cyan Individual Sewage Disposal
System at:
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Location - Address or t o.
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........ . ........ .................. . ...... ..............
OwnerAddre . .........
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............ j��j&�.�APA*CD .....i.<..........---•--....... .................. ....... 4
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .,., .....................................Expansion Attic Garbage Grinder
R4 Other—Type of Building ............................ No. of persons ............................ Showers Cafeteria
0.4 Other fixtures ......................................................................................................................................................
Design Flow .......... S:J; . .....................gallons per person per day. Total daily flow.. -3,3.,0 ......................... gallons.
Septic Tank 4- Liquid' capacityl.00.gallons Length ..... 7 ..... Width ... S . ........ Diameter ................ Depth................
WDisposal Trench — NoZ.F A . Width ..... 7.
G16 ......... Total Length___ 4D.F ..... Total leaching area ..................sq. ft.
,
Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0--4 Percolation Test Results Performed by .......................................................................... Date.....................
1.4
,4 Test Pit No. I ................minutes per inch Depth of Test Pit...--............... Depth to ground water.............._.........
0.4
04 Test Pit No. 2 ................minutes per inch Depth of Test Pit.................... Depth to ground water........................
* ...... " ------------- * .... ** ------------------
Description of Soil ..........................................................
......................................................................................................................... .....
Nature of Repairs or Alterations —Answer when applicabie...'=:r.&,�r, " -V
............... -7 ...........................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T LE 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 by ffie bard of health.
Signe ... ... ... ............
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Application Approved By. �
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Application Disapproved forte follo g re ons: ............................................................................................ Date---•----...... .............
..................................................................................................................................................................................
-�k Date
0 - _� — 1�1 (_ _CT
PermitNo .. ................................................... Issued ......... �e ...................
Daft
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Urfiftratr of Tompltaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
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. ........ An
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has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
... ........
application for Disposal Works Construction Permit No... . .. a .................. dated... . .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIQN SATISFACTORY. 7,
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DATE............. 3 ....... ....................................................... Inspector ........ .... . .................................................