HomeMy WebLinkAboutApp-Permit-ComplianceQ _ req YARMOUTH HEALTH DEPT.
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THE COMMOIg'gr=)KAFZWNGOTIIIIAicV* td& TTS
BOARD OF HEALTH
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Appliration for Elispaoal Works C9unstrurtinn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (,c,.) an Individual Sewage Disposal
System at:
Location - Address
Owner
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Installer
Type of Building
Dwelling — No. of Bedrooms.
Other —Type of Building ---•
Other fixtures
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--- ------------r. Z, t No.. ......... . .
Ve
ddress
-- .....
Address
Size Lot ............................ Sq. feet
.........................................Expansion Attic ( ) Garbage Grinder ( )
...................... No. of persons..---.-------------..------- Showers ( ) — Cafeteria ( )
... .....................
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity ............ 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-----------------------------------------------------------------------------------------------------------------------------------------------------------------------
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Nature of Rr s —
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS: 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issjued Eby the board of health.
Signed.cj..HAM `'Q"- A1Qm-------•-------•---------- --- ---
D I
Application Approved BY
.............................................
......
Date
Application Disapproved for the following reasons:....
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Date
Permit No...... ................................. Issued -lO y .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....�..UCU�I ...................OF...... u.r.MPK k... ...
rr�� ..........
Tatiiird le of (hum .fiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ...............
...�
/ F Installer ,
at..............................................---------------------•-------------------•------ ----------------------------
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.-_,__=:_,____ e______________ dated --_..(__1.. -1 .......................
THE ISSUANCE OF- THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. - ......r t t = -Inspector... ---- -.......................................-.-----------------........-----