HomeMy WebLinkAboutApp-Permit-ComplianceNo 5..'..�. (7 FEz... i s . _...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratinn for Disposal Works Tonirnrtion f rrmi#
Application is hereby made for a Permit to Construct
System at:
..--------�.�_ 5`.?�..l.J-...... -----•........................
--- ocati-n:-Address
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Installer
Type of Building
Dwelling — No
Other — Type
Other
) or Repair ( v�' an Individual Sewage Disposal
........ M• ),� - ,�)- -- � - �-_ IE .........................
or Lot No.
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ikAdd ess �' �
Address
Size Lot ............................ Sq. feet
of Bedrooms ............................................ Expansion Attic ( ) Garbage Grinder (A/C
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
fixtures..---•-•----------------•-------.............---------.----........------........-------------•-..........-----------.......•----------.....----------
Design Flow ---------------------------------------
per person per day. Total daily flow ............................................ gallons.
Septic Tank— Liquid capacity.1Q......gallons Length ................ Width ................ Diameter................ Depth ................
Disposal Trench — No ..................... Width .................... Total Length .................... 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. I................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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Natq-re of Repairs or Alterations —Answer when applicable._-��`. _"..A.&�.'` ...QCT ..
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Dispdsl System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by th�.of health.
Signed.
Application Approved By...V..................................1:.....
Application Disapproved for the following reasons:.........
Permit ...... .. .... /
No.. -25---
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Date
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Date
Issued. ...... 5 .....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
&r#ifirate of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (tj"
by....Inst
.........C.Q".t--------------------------...................................................................... .........................
nstalllerler
at.----- .. 5. 14 4 �- --------- aJ ----------------------•--------...-------------------------...-.-------------------------•-------------•------.----.._.-.-.--.-----.---
has been installed in accordance with the provisions of TI -TLE 5 of The State Sanitary Cod . as described in the
application for Disposal Works Construction Permit No.._1 . =:_ .... _(.................... dated... _ _.. �5.... � .5.__........._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G
'VA THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,r
... ........
DATE --