HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
, ppliratiun for Disposal Works Tonstrurtilan f rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
System at
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�% Loc p'ddre�ss
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Installer ��G% Address
Type of Building Size Lot -._------------------------- Sq. feet
Dwelling—No. of Bedrooms.............:..............................Expansion Attic ( ) Garbage Grinder ( )
py Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ...................
---------•----------------•--
WW 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.
3 Seepage Pit No ..................... Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by .......................................................................... Date ........................................
,aa 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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0 Description of Soil ........................................................................................................................................................................
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U Nature of airs Altera ons —Answer when applicable..;.. . _ �__�.�.�°�.--- �.!:............: ..............:��'
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Agreement: j'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' ed by the
boarg
of h alth.
S' ned ` Z
..................•-•--------.-• . ...Application Approved B ....._ f_.... �---................••....... _. ,...- �' �at -
D to
Application Disapproved for the following reasons: .........................................................................................................._..
.............................•--•----...------.....----•••-•••••-•••---•••••-•-•--............-•---..._...-•-•-......_........_....•-•--....._--••-..•--- --./Z.5
..............-••...........----•-
�'� ••.. � .. •-... .Date
Permit No....... ................... Issued._.._......-------.....
Da
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
farrtifirtttr of T antplianu
THIS S,
,TO -CERTIFY, That Pe Individual Sewage Disposal System constructed ( ) or Repaired
by
has been installed in accdrdance with the provisiollK. of TI
application for Disposal Works Construction Permit No....
THE ISSUA.MCE OF THIS CERTIFICATE. SHALL
SYSTEM WILL FUNCTI"ON, SATISFACTORY.
DATE.............. �':� i. C � .................................
4t
Inspector
State Sanitary Code
........ dated_....
TRUED AS_A,Cs4A1
in the
(E THAT THEs