HomeMy WebLinkAboutApp-Permit-ComplianceNo. ............ . ....... Flys......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrudiou'prrutit
Application is hereby made for a Permit to Construct or Repair ( Yr an Individual Sewage Disposal
System at:
t.-
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Location - Ajdress or Lot No.
.......... . ............................ ..... ................... _c
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Owner Address ..
I . ...................... --------------- .......
.... 6LIr
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms ... 3 ------------------------------------ Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons._.........___......._.._._. Showers Cafeteria
Otherfixtures .............................................................................
Design Flow ....... ��_.17 .......................... gallons per person ver,day. Total daily flow ........ .................... gallons.
4- Liquid'capacityIDCV.gallons _ �ength .... 9 . ...... Width._ ..
Septic Tank ....... Diameter......._........ Depth--..............
Disposal Trenches No.110-&ZS.. Width... . 2� ------------- Total Length..s��.! ....... Total leaching area ...................sq. ft.
Seepage Pit No ..................... Diameter.---.........__.._.. Depth below inlet---.._.........._... Total leaching area .................. sq.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ................. oo .....................
1.4
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.........._._.._......._
................................. **_""""__",,
Description of Soil ........................................................................................................................................................................
M.............................................................................. .........................................................................................................................
U Nature of Repairs or Alterations — Answer when applicable_.__=.tV,(—j.Aj_j .....
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/1P
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage DisposA System in accordance with
the provisions of T I T 1Z- 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 the board of health.
Signed. ....... ......... ... 4 , ,
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ApplicationApproved By ....... -- -- ---- - ...... ............................................................. ........... I .......
Date
Application Disapproved for the folio 'ng r r ons: ..............................................................................................................
.......................................................................................................................................................................................................
Permit No......I ZO .............. . .... Issued.....- .........
... ..................
/Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tntifirate of Toutplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by........... * ................... <_�..A. 112 1E. ]—.A N.A.. < ......................................................................................................
at--•--• .............. .. VVa. - -------- .............. ............. .................
has been installed in accordance with the provisions of TI TIE 5 of The State Sar as described in the
Sanitary
application for Disposal Works Construction Permit No.._= ...............dated.... .. 2
T" .�:�.. t ..... . .............
THE ISSUANCE OF iTHIS CERTIFICATE SHALL NOT BE CONSTRUED AS 7,-4 ARANTEE THAT THE
SYSTEM WILL F FACTORY.
DATE...
....._.............. Inspector -.4 ----- .. ..............................................
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