HomeMy WebLinkAboutApp-Permit-ComplianceNo._-l..Q 3 2. b
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Fss ....'5-
.�..Y ....
Appliration for 11isposal Works Tonstrttr#iatt ijrrmft
Application is hereby made for a Permit to Construct ( ) or Repair (V/) an Individual Sewage Disposal
System at: -•�
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------ ___..__. ....- ...-'•.................. . •- .......... - - ---- ------ ----- ...---• • - ........ .............
ocation ddress -- . .---.- or. Lot No.
.._ _� �.... ...... wnec ... K.Y... .................... ...... .� �1l.SJ��L. S.. ss.1XMl.l�i�:.Y. l�.✓...lM�`�—S) L! �
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Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling — No. of Bedrooms -----.S --------------------------------- Expansion Attic ( ) Garbage Grinder ( )
Other Type of Building ............................ No. of persons........................--.. Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------•-----------..............--...........--.....------------------....-----•----...--••-----...................__..
Design Flow .......:.-:A ......5.5___.gallons per person per day. Total daily flow------------------:110........---gallons.
Septic Tank—Liquid-capacity.GW.0.gallons Length._'? :.ems--..- Width_ -�i.:.5---_ Diameter ................ Depth. 4...�.S.....
Disposal Trench — No . .................... Width ...... :............. Total Length............,,...... Total leaching area ................... sq. ft.
Seepage Pit No ...... I.......... Diameter......1.0 ....... Depth below inlet ...... `.t........... 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..............•------------•----------.........---•-----•--------......-------•----------------....----.....------------•--•-------------.........-------••--•--•.......
.....................••----•--•-------•-•--.......................----........---•--•-----•-•------....-----••---•---...-------•-------•-----.....---•---•---•---•--................---..........--------
----•--•-•---------------•-----------------•-------------------------..--...--•---------•---------•---------------•---------.....-•-•--------------................---•--•.................---- .--.. nn
Nature of R airs or Alterations — Answer when applicable--
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 the board of health.
g 'Y�'l �? csv e . � ,- ` 1. a
Signe
Date
Application Approved By..-- --------------------------------------•----------------- ate
Date
Application Disapproved for the fog' ng easons:-------•-----••-••----------•--•-•------•••-----•._...-•................•--.......--••-.._............----......
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Permit No... c� .. 3......................... _.... Issued... --
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(9rrufirate of T%antpiittnrr �
THIS IS r'O CARWY, That tAe jndividual. Sewage Disposal System constructed ( ) or Repaired
Installer
atl � ot....-----...........---•-..----------------------------------------------••-•--•-----•----------•-------•---..............
has been installed in accordance with the provisions of TITLE of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ..... � ....._..3 ............... dated......`�-.5` ..R ..............
THE ISSIJAN E OF T IS CERTIFICATE SHALL E CONSTRUED AS vARANTEE THAT THE
SYSTEM WILL f U CThON S ISFACTORY.
DATE...................................... .......................... Inspecr......_- .....