HomeMy WebLinkAboutApp-Permit-ComplianceNo.. .......
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion famit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at, 4, R g /0',
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/Lo ca UDn:Address or Lot No.
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Installer Address
Tie 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 ............................................ 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 arm ................... 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....___..._._...._..__..
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Description of
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Nature of Repairs or Alterations -,Answer when applicable--- ........... :�� ..............
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Agreement
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Agreement: vzto—JL:��
The undersigned agrees to install the aforedescribed n-ervidual Sewage Disposal System in accordance with
the provisions of TAI TIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been * sued by the board of 11 Ith
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Signed..
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Application Approved By.... . ...... ... . .................... --------------------
7 Date
Application Disapproved for the follbwing reasons:....
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Permit No.----...._. 90— lcq S ................... Issued ... Date ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntif irab of Tvntplianmiv'�� to
THIS IS RTIF h t dual -Se I . posal System constructed or Repaired
by.... ---r ................ ........ ...... . ........ .. ..... .............. V9.
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Installer
at........................ ........ ............... .... ................................................................................................................. m .................
has been installed in accordance with the provisions of TIT State Sanitary Codtis escri the
0. .......... ........ ... .1ZA N& ........
application for Disposal Works Construction Permit No.._____
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THE ISSUANCrE OF THIS CERTIFICA'r= SHALL NOT Bg��ZPNSTRU D AS tjUTVIN�TE HAT THE
SYS"" WILL.,y1mr,
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