HomeMy WebLinkAboutApp-Permit-ComplianceNo... ��. .
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH.
TOWN OF YARMOUTH
Appl ration for Bisposal Varks T anstrurtiun Frrmit
Application is hereby made for a Permit to Construct ( ) or pair ( ) an Individual Sewage Disposal
System at:
..................... .y.............•-------- ......------....._... ZI
...------ P �ocation -Address�/k IP
a
----------------------- ............. �/__.�`i� &J(-
el A./.V'__..C.�. ff.............
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms......�.............................. pansion Attic ( ) Garbage Grinder ( )
a Other — Type of Building ........................... No. of perso s ................... ........ Showers ( ) — Cafeteria ( )
Other fixtures .............................. ---
W Design Flow ............................................ gallons per p rson per day. otal dai flow ............................................ gallptis.
WSeptic Tank— Liquid ca acit A92AL. allons Len � Wi 5 Diameter...... Depth...
x Disposal Trench = No ..................... Width ....._j.............. tal Length.............. Total leaching area .................... sq. ft.
Seepage Pit No.._._, ........... Diameter........�Y.6... Depth elow inlet .................. Total leaching area .................. sq. ft.
Other Distribution N x ( ) D "ing tank ( )
Z Percolation Test Results Performe Y •.....................•--.... .............. Date ........................................
Test Pit /No. A ---------------- minutes p r inch De th of Test Pit ................. .. Depth to ground water..................._.--.
i, Test Pit No./2......... ...._. iinutes pe inch Dep of Test Pit ................... Depth to ground wat ........................
P4 j l
Descrition of Soil ................... •.........................•------------....................................... ................................... .P.....;! _.._L---•----------------- ----------- .......................... .................................... -------•------•---•-------- ...............................
r
UNature of /Rpairs or Alter do s - n er when app ble.Agreement:
Thejl ut Aersigned agrees to install th aforedescri ed Individual Sewage Disposal ystem in accorda a with
the provIIsiollis of TITIE 5 of th State San' ary Code — The undersigned further agr s not to place the ystem in
operation until a Certificate of Co pliance has i ued by the board of health.
jSigned_ - - -------- - --•- ---
APplicati6n Approv BY----- -• --... .....-- .. ---- .... .... fl ... 3
......- - •-----• -•--------- - - -•--.. .. • -Date -- ---•----•
t
i t
Annli6 tion DisaDDrove for the follo ina reasons: ......................................................................... .............................
Permit
T
TO CFIR)TIFY,
H C+
MONWEALTH OF M/AASETTS
BOARD OF H
TOWN of YAR
Trrtifirttir of Torr
the divi al Sewage Diem onstruc
f-- -------------.- --------- ------ -- -
Installer
has been installed in accordance with tpe provisions of TITLE 5 of
application for Disposal Works Construction Permit No ...... ....-5a
THE ISSUANCE OF THIS CERTIFICATE SHALL N T BE C
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................................................•-------- Inspector....
Date
( ) or Repaired (k,)
...............................................................
e Sanitary Code as described in the
. dated .......... - -1 ? ...........
ED AS A GUARANTEE THAT THE