HomeMy WebLinkAboutApp-Permit-ComplianceJ _
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratinn for Disposal Works Tomitrurtinn 1C rmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( 4�ain_ Individual Sewage Disposal
System at:
-- • - -- ._......
Location -Address
................................
or Lot No.
....................�_..�........ �l a?!%.-..^------•---•------------------------------........................................................................................... --...-----------------------------..........--•-------........---.................................
Owner_-
v-•
Address
............
.................•------•------------••......__..
Installer
Type Building
_...._........... •.............................--------•---............................
Address
Size Lot Sq. feet
of
�
............................
Wo
Dwelling — No. of Bedrooms.......... .............
. . .....Expansion Attic ( ) Garbage Grinder
� Other — T e of Building
No. of persons ............................ Showers — Cafeteria
�4 Other fixtures --------------------------------
.
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Length Width Diameter Depth
Septic Tank —Liquid* capacity ............ gallons
................ .......... ...... ................ ................
Disposal Trench — No ..................... Width ....................
Total Length ........ i........... 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.................•------------------.............--•---------...........------------------------....---•--------•-----------
------------------------------------------------------•--•-•-------------------------...---------------- . j ..........
.l__.NatuKe o Repairs or Alaons—AnsweX�ir hen applicab.....l.i._j.__56...
Agreement WY
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 further agrees not to place the system in
operation until a Certificate of Compliance has been issued byitlhe boarA of 119K54.
........................................
Date
Signed--- ------- - --
Application Approved By. ...................... ------------
-----' C
Application Disapproved for the following reasons: .............. .....................
....-•-•------------------------------------------------------------------•------------....-----------..........--------..........------...------------------......................------------------•--
_i
Date
PermitNo ...... .-. �J.S......--•................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(9rr#ifirair of (faautpliana
THIS IS TO CE IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by------------------------- .....-----•---•--•--............._...--------...--•---......--.....------•-----------........................................-•----._
staller
atr- — —� --------------- ---------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Coe as described in the
application for Disposal Works Construction Permit No..,1 S .....3.52.:............ dated----- `l S .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE ................ 2... ---2.5 ................................ Inspector ... .��{'................h�_ ...