HomeMy WebLinkAboutApp-Permit-ComplianceNo.... �.. Fss...//
THE COMMONWEALTH OF MASSACHUSETTS GfL/jf/ted
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal Works Tonsirurtiun jjrrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( —1—an Individual Sewage Disposal
System at
-- --• - .-----•......... ....... ..
I.osa �/� or I.ot Nd
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Z)Lft�L _. ...---
er � • '70 --:dress [ �
... ........ ----------------------------------------- ------------------ ...._.
-t�: -..... 1
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (/�}
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures�------- •------------------------------------- •... ..... .-----------------------------------------------
��? .3 ...................... lons.
Design Flow ...................... ...................gallons per person per day. Total daily flow_..____ _._....._ gal
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....--..................
Descriptionof Soil .........................................................................................................
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Nature
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Na re of Repa' s or Al s —.nsw r when applicable -P7 /.... ... ............................ 1.7
Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned furth agrees not to place the system in
operation until a Certificate of Compliance has b d the 7c7:;
teSi ed----------------- .
�at
Application Approved By ................................ ..•- .... •--- ... ...
......
......
.................... -•----
Date
Application Disapproved for We following reasons:
Permit No.--••- ?�--- A19- -7 ......................
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Issued .............. /'.�1-- %....ate ......
Date
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THE COMMONWEALTH OF MASSACHUSETTS—
BOARD OF HEALTH '
TOWN of YARMOUTH f /
Tnfifiratr of Toutplittnrr
THIS IS TO CERTIFY, Tjhafi_the Indiviouo SeK��}ge Di§posal System constructed ( ) or Repaired (ej�
by................................................... I.X?
has been installed in accordance with the provisions of TITLE 5 of The State -Sanitary Code as described ------------
the
application for Disposal Works Construction Permit No ...... ._'�Q.. ........... dated .........�.1`•...1Z.-.�..._._......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A'GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE........... �� 1'� .. ....................................... Inspect ,,. .........