HomeMy WebLinkAboutApp-Permit-ComplianceNo....cl.°-- -a. J Flcs.....1.� ... ..:_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tons%nr#ion "ptrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (t—ran Individual Sewage Disposal
System at:
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Installer
Address
Type of Building
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms -------- ;F ---------------------------------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* 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 ........................
Description of
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Nature of Repairs or Alterations — Answer
PrA
.........................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Comm_ cP hasan is
st�ed Py the board of health.
Vumn'-neasoxs”
...............`�.._r_.GIST " ---•--....--•--------•----
Da
Application Approved By..........-------...._........-----------•--•---•--•-------
Date
Application Disapproved for th.......
•-•---...-•-•---------------------------------------------------------------------•-----.....-----••--••---•----•-•---•---------...---------.................-•----•---......-•---------••---.........»
Date
Permit No. -O �` �'
....._..-•----....»»» Issued ............. ------------ -
Date �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(frruftlratt of f OMpliann
THIS JS TOC RTIFY Tha�j e Individual Sewage Disposal System constructed ( ) or Repd>red (1--f
bY- •.. ��.. 1.
......... ........... . .......:....... .. ......................... ........ .....r
Installer
a licatiori' for Dis osal Works Construction Permit No.._ O___..? �..._-----:•------- datedy...-7 -'i. ....................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as d scribed in th
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CONSTRUED.AS,THE ISSUANCE OF TH15 CERTIFICATE SHALL AOT�IARANTSE''THAT THE
SYSTEM WILL F NCTIO� SATISFACTORY.
DATE......�2 ...: Inspector ....... ...................................:...---- ............
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