HomeMy WebLinkAboutApp-Permit-ComplianceNo.� � n3Z4
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonotrurtion ritrutit
Application is hereby made for a Permit to Construct
System at:
-. Loc, 'on -Address
.. _. �.--- ----------------------------------
- -•--
-- Owner
...............................
Installer
TvDe of Building
) or Repair ( ) an Individual Sewage Disposal
�
--...:f_ _m ......� _.
-'----- .. ........_.........
- -- --
-_-.-- or Lot No.
- ...._...........
Address
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' ca.pacity............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. I................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 ............................................................................................
•----•-•-------------------------------------•-----•--------------...._.....---•-•--------------------------...............................
r,....�...... -----
U Na f R Ors or Alterations A r when /aplicabUllee_�� -_.._./��__-_0-,-- ............
----E' `=rte^.._... - ..;�- , .....-Z...r-;� -••-------•-------------------------•-----•-------•------.---------.--•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLL 5 of the State Sanitary C e —The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has a su d RT=��K
Signed... ... .:..........--------....._
O Date
ApplicationApproved By..-- ....-- . .. .................•-•-------•-...............------------•--------• -•.. ......... . � ---
ate
Application Disapproved for the follow' g real:................................................................................................................
..------•-----.....•-------••-------•-----------•------•--•---•----------------------------•---••.........---•-•--•--------•--......_._....-----------...----....._....--q.......................... ..
Permit No..,,/' , ... r_';, ca 7 Issued......<._.D ...Z2 .-`..�
't� --------^................. ...... ate ......
Dat
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
0rrfifirate of Toutplinurr
THIS,J,V0j.GERTFy, That the - Individual Sewage Disposal System constructed ( ) or Repaired (X)
by
"t ........... ......... ....... c_� .x, ...._....fi-----------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ......................................... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION cSATISFACTORY.
a_ Inspeto....DATE.. ;.,