HomeMy WebLinkAboutApp-Permit-ComplianceaF, /X1_14, xlaep
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonsirnrfinn Frruti#
Application is hereby made for a Permit to Construct ( ) or Repair (V�/an Individual Sewage Disposal
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-AAdd dress
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Instaler ess
Type of Building IsSize Lot ............................ Sq. feet
a Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) IVO
p, Other - Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures ...................................... . .
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 ........................................
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
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Nature of Repairs or Alterations —Answer when applicable ... ................... .......................... ,... - .................. .
42:x.. .. , ' ..-------------------------------------------- .................---..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1L 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
overation until a Certificate of Compliance has been>lued by the board ofohealth.
Signed.
Application Approved
Date
Application Disapproved for the following reasons: ...........................{-----....-----.....-...........---------------.------------.__.---------------
....--•........................•••----••-•----...----........-•--••----•--••-----•--•.........---...----------••--•---••--------•-------------•-------------......................---------•----------•-
Permit No. - - __.._ Issued......... -..................... = - - au
Date ...
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trriif iratr of TuntpliUM
T IS TO CERTIFY, That,*e Indivr ual Sewage Disposal System constructed ( ) or Repaired (�
by ... ------�..t ....
/� Inst�lsrr� dbF�'d..l�� .[___/
at- C� :..... �-------------= �------ .............................................
has been installed i accordance with the provisions of TITM
of e tate Sanitary Cojoe as d -crib --'y the
application for Disposal Works Construction Permit No ........ __ _Vta... dateci___._1_�%_— �___"___.___..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARA RE THAT THE
SYSTEM WILL\ F�INCTION SATISFACTORY.
T � n �
T.III ./111 IC/61