HomeMy WebLinkAboutApp-Permit-ComplianceNo. ------------- ----•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Applirtttaan for Disposal Works Toustrurttnn Frrntii �
Application is hereby made for a P�ermi to C /strJ�ct ( ) (or Repair (x) an Individual Sewage Disposal
system at:-� � / '/ Q I/ ��-G� .�I� / 7 � ��✓ �
_ _ .. J/mn>�, � �
Installer — Address r
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............................•------.............------.------•---...............---•-----.......-----•------......•---••-•-........--•--•......•-----.
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........................
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Descriptionof Soil ..........................................................................................................
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Nature Repairs or t tion Answ r when
.....
Agreement:
The undersigned agrees to install the afore
the provisions of TIT1Z 5 of the State Sanitary
operation until a Certificate of Compliance has W
Signed.. .
Application Approved By .............
Application Disapproved for the following reasons:....
to,
bed Individual Sewage Disposal Systemm accor nce with
— The undersi d further agrees not to place the system in
led b oa f health.,,
._..
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.. .............•. •••....... /; at ---•-
Date
..-•................•---------------.....-•---•------...............--•---.........----.....------------•.-•---•---------------------------•------......---------•-•----•-..............-----............
Permit No....... : 2 -1 ----------------- Issued_ -------- _.. y d.. ........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#tftrate of Taautpitttnrr
THIS- T9_gL-RTJ,,FY, That the Individual Sewage Disposal System constructed ( ) or Repaired V)
11
at ............. Z .::........... ..... rel ------•1L- ' ............ 4'."/ '' (. _ -- I- =
has been installed in accordance with the provisions of TITLE 5 of he State Sanitary Cod as described in the
application for Disposal Works Construction Permit No ....... g1 k::- - .. Z........ da't. ed..... -�!�...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AV Al', ;EE THAT THE
SYSTEM WILL F NCTI,N SATISFACTORY DATE....::: _ _:.... ... Inspector ........... ........: .............. .....:...... �.......................