HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1S" _L10
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH Mpp
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TOWN OF YARMOUTH 40-12-1 C`� 1W 4a 4/
Appliration for Dispoal Works Tonstrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (D4 an Individual Sewage Disposal
System at:
................__....................................
---- ... .... - .... ......_..----•-----
p� Lo ation -; ress or Lot No.
.._.�
..................gig r ► [�—F�/l`. ......•. 4� . v
wv 746— ddress �1...........
`mew.....
1 ' ...... .............
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .................... !V ................... Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-----•----------•------------------•-------------------------------------------------------------•-----------•-----------------•------•--------------
Design Flow .................. ..tom' -�------------gallons per person per day. Total daily flow ................ .L%-_f%.�................. gallons.
Septic Tank — Liquid capacity./(fk; ...gallons Length ................ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width .--......_._.._..... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No........../....... Diameter......Zd_..._.. Depth below inlet....... P_.-------- Total leaching area..................sq. ft.
Other Distribution box (yq 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--------------------------------------------------------------------------------------------------------
-----------------•---------•--•----•-•---•--._...--•-•----------------------------------------••-----•-••--•......_-----------••-----•-•--- . -- •• ------•-----------•-•••----•-------
Nature of Repairs or Alterations— swer when applicable .______,6A16___ .9 ......... ._
..®.1�-----2--014-t-------� 11 A t'7—�may— r7zr------. • �3O.-- ...7 6'A(,�tlKr�
Agreement: 1T V 0 4-+1- ';;�J `7— k i /-774 S'nJ � ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal
al System in accordance with
the provisions of TIT11, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i l by the bo health. 77
Signed---- -- --- ---- - --•- ......... .......................................... ...... -•--• ........
ApplicationApproved By------ --•-- ...... .......................... . ............................... ----- -1jn t � ...
Date
Application Disapproved for the following reasons:-. ............ .............................................................. .................................
o
Permit No.. -..7. � -----�--------- -------------------------
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Date
Issued. ..... �5 . at ...----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tn tifiratr of Toutphatta
THIS IS TO CERTIEY, That the Individual Sewage Disposal System constructed ( ) or Repaired ()
O% O C¢� ► �. s�..0 c �-"7 G.r•?...---•--•---------•----------•------------------------------
by---•-------------------------------------- �.... ._.
.� . L�£1� In ) - `�c�__� `_.._..1................................................
at. `�'' ---...
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Co ie as escribed in the
application for Disposal Works Construction Permit No.�-�._.A-�`_.�U l ............... dated___' j._�477., .__._.._...._..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ................/'!..` 1 `� C-� Inspector ............... ..... 4�..