HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Totts#r ' n prruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.........i2 _fie ... 4 ................. _...........
o tion - Address
------- .._. 21�%..�.0 ..........................................................
,--;—� Owner
Installer
Type of Building
Dwelling — No
Other — Type
Other
- or Lot No.
..............••-•------•---•-- .....
/ • Address
--- r� ,C!� _il_...............................................
. Address
Size Lot ............................ Sq. feet
of Bedrooms.... -,3 ................................. Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
fixtures.......................................................-----------------------------------.......---...-•----.....------------•---•------._...........
Design Flow............................................gallons per person per day. Total daily flow -------------------------------------------- gallons.
Septic Tank — Liquid capacity ------------ 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. 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 ........................
Description of Soil ............................
.................•----------•----------------------------------------------------------------......------------------------.--------
Nature of Repairs or Alterations — Ans er exp icabl ; _ �'rr -�.1 .: .......................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT%L 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 bt�yhre br"rd of ,health.b
ned....:".........................
---- -•-•--"7—
Application
:1`.
Approved B = .._..Date
Application Disapproved Tor the fllowi�lg reasons------------------------------------------------------------ i.-......-....-......------------..-..-.-----•------
-----------------------------------------•--------......;-----11-........--------------------------------- ...L--- ;;, 1 ��---------'Date---------.----
Permit No ...... .-.•.. j 2 �..`-� 1 ..................... Issued
.....
°•--•� ------Date .�..........---.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
hirrfifutt#r of 09-itut pltttitrr
b ..THIS IS TO CERTIFY t the In ivid Sewage Disposal- System constructed ( ) or Repaired (G.�
y............................•---•---2-.� ----• ....................-�...
InsJt�11,
a* -- ll_S �, J� , _ /'t' �- t _ 1/l_---------------------------------------------------------_.....---d......---.....:
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has been installed in accordance with the provisions of TIT 1
5 of,' e tate Sanitary Coc e s r' the
application for Disposal Works Construction Permit No._...__ Z.�- [--........ dated___........
THE ISSUANCE OF THIS `;CERTIFICATE SHALL NOT BE CONSTRUED AS A, GUARANTEE THAT THE
SYSTEM WI _.FU TION SATISFACTORY.
..d
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.:
DATE.: .................... . .
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. . = .... Inspector......r --