HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS `\\\
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratiun for Disposal lVarks Toustrurtion 1rrutit
Application is hereby made for a Permit to truct ( ) or Repair) an Individual Sewage Disposal
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A,ddress - fe Lot�........1.---...----•---•....................... 5.. /._..a���d76!✓...'' -_•l. �rS.......
"Owner-_--... . ---
.. ?. ...........................•-•--........... -_ - ...................................................
installer Address
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 ............................................
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. 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....................................................•----------........--•----•--.____
.................•-••-•---•--..................--.....---_......................
Natur _ f Repaid or. Algations —. Answer v
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Wsposal System in aance with
the provisions of TITLE 5 of the State Sanitary CoThe undersigned further agrees not to place the system in
operation until a Certificate of Compliance has biss y e bo of 1 lth.
igned. -• • ......... ........ . --•/ -•D -•-
Application Approved B ... ..... __..... ------••-•--•-•-•-••---.--•--.................................. l .. a:S'
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.................... ........ ..... L ate .....---
Applieation Disapproved or the following eason:..........•••••.....----•••-•-•-•...................................................... ......................
................Permit No ............ ...r ..................
-•-•-•--•--------•---------........Issued ..........k._ ...�_..
ate
Permit
Date
THE COMMONWEALTH OF MASSACHUSETTS
,
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtifiratr of 09autplianrr
THI r7,•�RTI Y, That the dndividual Sewage Disposal System constructed ( ) or Repairede)ry
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has been installed in accordance with the provisions of TITLE 5 of tate Sanitary Codf. a descrtHAATE
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.application for Disposal Works Construction Permit No...........� �'�'� _____ dated.......�...'Z�`��
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUAR NTEE
SYSTEM WILL FUNCTTIIO SATISFACTORY.
DATE ....... :::.:-? —.:1 .... ............... — .:.:. ZV .... %?'}�-
........................ Inspector.... ._.....-./..... --
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