HomeMy WebLinkAboutApp-Permit-ComplianceNo... .... D Fxs..... S......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tottsirixr#' n � Vrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at -
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Location -Address/�/ gyp, �J or at No.
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��OwnerAddress
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Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ---------------------------- Showers ( ) — Cafeteria ( )
a Other fixtures -------------------------------•--------------
W X45 Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
We — Septic Tank— Liquid' ca.pacityfg??R---gallons Length ................ Width ................ Diameter................ Depth ................
x Disposal Trench — No . .................... Width .................... Total Length .................... Total leaching area _................... sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet__.. _._.._..._.,.. Total leachin���..........._...sq. ft.
Z Other Distribution box ( ) Dosing tank( ) 51p c, ,4_ a
Percolation Test Results Performed bY--------------------- ----------------------------------- Date...
,aa 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 ........................
x
................................ =-------------------------------- .._..._. ..................
a ._...
Descriptionof Soil .--•- O- • �-..... ..._....._..�................�---•--------....---------•--.......... .......
re �� .
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UNature of Aepairs or Alteration —Answer when�1.a��.._.5..�.,_�.'_�.........._C �
1.✓1_. (' = L-.../` ! f?J s — a2'_ s 7�flin-e d P/�-ted e �^`Jj 5� o! <i� c� ems_
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA 11 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been • �ar��h It
Signe--• ---- . ---- -•--•------------ ----••--------•---•-••--••--..._...... -
�• te �y�
Application Approved By..,.'. ---- -----------............................................................. ---- [`
Date
Application Disapproved for the f oll wing reasons- ----------------•------•---•------------....--------•-•----•--...........------•--._........-••-••......--------
--------------•--------••---••-•----•-•---••-•-•----•--•---••••--•••----•---------•••-----•----•••-•-••-......••••---•--•-••-•-•-•-••-----•-..._.........•••--........----••-•-•...---....•----•--.....
Permit No.. 1.1... i� �............... Issued........ �`�.---
-. �•- . I-_------ a� ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifirate of Toutpliam
THIS j gC ER��LThZat Jthhe Individual Sewage Disposal System constructed ( ) or Repaired ( )
- -- ------------------ }--------------------...------------...................---------....-•-•----•---........---•---•--.................................
Installer
C
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Codg as described in the
application for Disposal Works Construction Permit No.--` �-_-_Ld-�........ dated......57-.6.� ..�..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE .......................... . ... .....••--•-- -- -------_.._.. Inspector_...._ . ...... .....