HomeMy WebLinkAboutApp-Permit-ComplianceNo. ... _....). Flms...:��............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Applirdt#ion for Disposal Works Toustrurtion jJamit
Application is hereby made for a Permit to Construct ( ) or Repair ()C) an Individual Sewage Disposal
System at:
................ _. � 1 _. ... .:.s .............................
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Location - Address
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...............................
Ow er
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Installe
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//'� or Lot No{
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i`�ddresst
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Address
Type of Building Size Lot... ......................... Sq. feet
Dwelling —No. of Bedrooms ----- 3 __________________________________Expansion Attic ( ) Garbage Grinder (
Other — Type of Building ............................ No. of persons____________________________ Showers ( ) — Cafeteria ( )
Otherfixtures.---•.............................................•--..--•-----•-•-----------•------------•-•---•...._.....__......_.._...._-•-----•-••---•----•---_--
Design Flow...........5_:> .......................gallons per personer day. Total daily flow ..... I ........................ gallons.
Septic Tank A- Liquid' ca acitylgallons Length___ •----- Width__ .!� __._.____ Diameter________________ Depth ................
Disposal Trench —No.,!L___ Width _._._ i________ Total Length.___3d........ 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 ........................
Descriptionof Soil .........................................................................................................................
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Nature of ReRairs or Alterations Answer when applicable_ ___ t6
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned furtheagrees not to place the system in
operation until a Certificate of Compliance has b sued b oaz>fk�.
Signed_.
7
_Da_l-t_e_
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._. . _ Application Approved By. ..• .__._....--•---• .... `
/
Date -
Application Disapproved for the following reasons: ..................... f__.._...../-________________
.............................•--------------------............_.....----•-....-----._.........._...._..--•--------------------•--------•-------._......_..............._..--_.._ _..
/ ate
Permit No .......... ---=�------------------ Issued ................. 7.�L�---. _/ .............
Date
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THE COMMONWEALTH OF MASSACHUSETTS — —
BOARD OF HEALTH
TOWN of YARMOUTH
T fifxrate of Toutpiianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( L)-'
by------------------------------------:. rte! f - ......_._......._:. .... - ....- - ........._.._........_
;-� � Installer
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as describe in the
application for Disposal Works Construction Permit No.__----�� _.-:�� �---_---- dated ........... -;!�"_ ______.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. Z"
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DATE_...............7.`. '-----------------------------------Inspector. ;, =- /