HomeMy WebLinkAboutApp-Permit-ComplianceNo. S...331 Fx$........5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Dhipoiittl Works Tonstrnrtion 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( n ndividual Sewage Disposal
Type of Building
Dwelling — No
Other — Type
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................ ...... ..
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Addres
ddres
Size -------------- ---- ----Sq. feet
. of Bedrooms_____________
....• ....................Expansion Attic ( ) Garbage Grinder (NZ))
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures-------•--------------------------------------------------•••-•-•--•••-------•----------•---•-••-•-•••-•-•-----------•-•-•---•......---•--•--••--•--•
Design Flow -------------------------------------------- gallons per person ner day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity__DOQgallons Length._a-__ �. --- 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 ........................
----•-....-•---------•-----•.................................•----------....•--•---••------.........-----••---•--••-••----...._......._.......---•----•---••.
Description of Soil ..................................... r-
y
............................................................ .......................... 6..ice-.... ^ �v � i `yW a---- r'
--------------------------------------------------------------------------------------------------••----•••--`
Nature of Repairs or Alterations — Answer when applicable..., 600 ____ ....-- 6� 9r "..-�' .
..-•----•-------------------•----•------------------•-•---------.._....-•--•------............•••----•----------•••--•------•---••• •---••••-----• •••--•--------••••••---•-•••-••-----•-.................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT11j, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bees issued by the board of health..
Signed. ----- -_ W'de�---........ 5 ---
DIV,
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Application Approved By ----...._ .� -
D
Application Disapproved for the following reasons: ---------• ............ •-•••••--------•----•---••---••--•----•---•------•--•-•------•..............•-------•-
.----------------------------------------------------------------------------------------•--•---•-----•--....•--------•------•---.....--••---•••---•----••----•--••••---•--•-•-...
3,3 1 dye/ Date
PermitNo ...... ..•---•-- -----------------------------•-------• Issued ----- _. L.1........ --•--------
Dat
— — — — — — — — — — — — — — — — — — — — -- — — — — — — — — — — — — — — — — — — — —
— — — — — — — — — — THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH G�
TOWN of YARMOUTH
(fatifiratr of Tomplittnrr
THIS S fi0 C TI That the In( ividual Sewage Disposal System constructed ( ) or Repaired
by..----------------------------•--------------............----------•------•.
-alai 5- Installer
has been installed in accordance with the provisions of TITLE o The State Sanitary Coe as described in the
application for Disposal Works Construction Permit No ...��= �-�.................. .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEMA WILL FUN TPN SATISFACTORY.�
DATE .............. 3��2�. '..........------...............--•-•---•-•------ Inspector. ...... ......... •--•GjC-. �T�1 J .