HomeMy WebLinkAboutApp-Permit-ComplianceNo. Fa$.....% .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Toustrnrtiun ITrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
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�Loca ' --Address or Lot No.
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QvYner.-------• Address
............................... .... ........................... -•----............................---•-•------•-----............................
Installer Address
Type of Building Size Lot ............................ Sq. fejt
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 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. 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...................:....
Description of Soil ..........................................
........ .
Nature of Repairs or Alterations — Answer when
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Agreement:
The undersigned agrees to install the aforedescribed
the provisions of TITA IE 5 of the State Sanitae — i
operation until a Certificate of Com liance has leen iss
/ ;m/ Signed
Application Approved By
Application Disapproved f
Permit No......:.. 2 ---------------- -
-
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......... � .-%.' •-- .. _f9 CC_..........
Evidual Sewage Disposal System in accordance with
undersigned further agre s of to place the system in
TeardatTie-al�t�.
? �3
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Date
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auIssued-........... _-
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Date
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�..� THE COMMONWEALTH OF MASSACHUSETTS
{/01 BOARD OF HEALTH ��•�
7
TOWN of YARMOUTH Al VVV
THIS IS
by- .....................
at............................................. �"./V...... &a:>.r1.l-----------------.........-----------------------..........------....
has been installed in accordance with the provisidns of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ------- -............ dated ........ *r. ..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUA=THASYSTEM WILL FUNCTIONS ISFACTORY.
DATE................1... f� _._--� •----•-----•------------------- Inspector...--- . --- -- . �.