HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Dispnoal Marks C9,anj5#.rnr iun� Vrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair-,( ) an Individual Sewage Disposal
System at
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Location.Address-or Lot No.
.._.. •------ - ______........._. ..................... - ......... --.. ----------•---•-----------
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Owner Address
LO
pq Installer Address
VType of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms..-.`..C....................................Expansion Attic ( ) Garbage Grinder ( )
9144 Other —Type of Building ............................ No. of persons.-, .......................... Showers ( ) — Cafeteria ( )
Otherfixtures ...........................................-----..------------------------•-•-•------------------------•----•----•-----•---•--------------------------
W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid' capacity --------_--gallons Length ................ Width ................ Diameter.......--....... Depth ................
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
`" Percolation Test Results Performed by.......................................................................... Date ........................................
,-a
Test Pit No. 1................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
LL,^ Test Pit No. 2--------------; .minutes per inch Depth of Test Pit .................... Depth to ground water ........................
0 Description of Soil .....
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U Nature of R airs or Alter tions — Answer w eri applicabl . . ........... i b0 O B J. k w t �-
Agreement
The undersigned agrees to install the aforede d Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 5 of the State Sanitary de — The undersigned further agrees not to place he system in
operation until a Certificate of Compliance has bens ed by Vie boAof th.
, -
Sig ed _...._2
ate
Application Approved By------ --- .. ...........•---- , . ....----' 2 `
Date
Application Disapproved for the followi g reasons:...............................................................................................................-
............................................................... -•------••---••--------••------•---------...-•--............_..--------•----•-- ....................................................
Date
Permit No ...... ' . �..................... _.... Issued.-----... `... ...............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tatifirate of Tomplittnrr
THIS IS TQ CERTIFY That the I dividual Sewage Disposal System constructed ( ) or Repaired (V)
Installer
at.....---'--•.•••. C.. nr�w ill ......r (c +C!}o �t......__ cx ...._......•-•-•-
has been installed in accordance with the provisions of TI 5 of T e tate Sanitary Cod; as s ribed in the
application for Disposal Works Construction Permit No.._....... -._�..... ..... ...... dated....... ....... �.�...
THE ISSUANCE OF THIS CERTIFICATE SHALL NCNB � V NSTRUED AS GUARANTEE THAT THE
SYSTEM WIL FDNC N SA SFACTORY.
DATE ...... ....... ...--..L_-G�„.....................Ins ectoz -- .........
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