HomeMy WebLinkAboutApp-Permit-ComplianceN
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstr rtion Prrmit
Application is hereby made for a Permit to Construct
System at:
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.......1.. __.._....f....._.....O�Ce!s�:> .....................
Location . Address
...---._ .,'.__ ...:�.Q..... ........ ......................................
Owner
•
,r4.t. .....C' �.0.-•.........................................
Installer
Type of Building
Dwelling — No
Other — Type
Other
) or Repair ( ) an Individual Sewage Disposal
. or Lot No. --•......................................
Adda
-- „�
Address
Size Lot -......• ....................Sq. feet
of Bedrooms............ 2..........................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. 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........................
Descriptionof Soil .......................................... :...............................................
-•................•---------............_..•----..................•--------------..._...---........•---.......:.--•-•----•---.... jj-----.......
N ture Re airs or Alter tions — Answer when applicablet.1fl.1f�9 h... ..'.. _�± y._.. �d�%......� . �.......:..,� G
� .a,l�.... 1... . p..._./..Qa_ ........
... .......
....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issu d the and iealth.
Signed... ... ........................''
Application Approved By ...................... ........................... ......... �a.........`...
Date
Application. Disapproved for the following reasons: ... ..........•-••---...-•--•-------..............._...........---•.-•----.................................
....................................•--•--•--.............•................---•-------------•------------.......--------...---------------•--......._•-•-----...... ...................................
Date
Permit No....... ..............•• Issued........... �.._.......---•--------
ate -
THE COMMONWEALTH OF MASSACHUSETTS
B ARD OF HEALTH
OWN of YARMOUTH
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S, (arrtifirate of Tontplittnrr
THIS IS TO CERTTIY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ............. �-f_.r�„�........ ,,:�317.C..G......................................... .............:..........................................................................
.....--
l) i it/, / Installer,
—------------- w --------------- ...... _—------------ —""— ----------- _----- ______-__
has been installed in accordance with the provisions of TIT 5 of The State Sanitary CodVas de• ribed in the
application for Disposal Works Construction Permit No._ ---q. ^l-��-r�........ dated.......j........ . ..............THE ISSUAN E OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AEE THAT THE
SYSTEM WILLSATISFACTORY.
DATE ......... Z.... ............... ............................. Inspect
Inspect .......... ................ .......:. _.........
J.
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