HomeMy WebLinkAboutApp-Permit-Compliance01, YARMOUTH HEALTH DEPT.
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THE COA0C;NWEAt.F i& UASR6aUSETTS
BOARD OF HEALTH
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Appliration for OF
Works Tonstrnr#ion ra mi#
Application is hereby made for a Permit to Construct
System 6vx,� ID 92j,
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Installer
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Type of Building
Dwelling — No
Other — Type
) or Repair (56) an Individual Sewage Disposal
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Address
Size Lot ............................ Sq. feet
. of Bedrooms...................v..-.............. Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures-------------------------------------------------------------------------•---------------..................
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--.... •------------------- -
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Design Flow.................l.� ................. 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 ......_.._....,t --- sq. ft.
Seepage Pit No ........... �........ Diameter......��.'..S Depth below inlet ...... ............. Total leaching area...4Z ._....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 o Repairs or Alterations — Answer when applicable. G'�.. 4 ¢'.....
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Agreement:
The undersigned agrees to install the afor des ibed Individl Sewage Disposal System in accordance with
the provisions of TITil, 5 of the State Sanitary C de — The un rsi ed urther agrees not to place the system in
operation until a Certificate of Compliance has be issued y th b d of he lth.
. �...
ApplicationApproved By ............ - -- --------------............. --------•-----•--------------------------•................... .i ...-----
Date
Application Disapproved for the
Permit No. �Z._ :/Z..
reasons- ---------------------------.
--------------------------------•-------------------------.....-------...-----.........
Date
THE COMMQNWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Trr#ifiratt of Tomptiaure
THIS IS TO CERTIFi'Q-11hat t ndi - ua wage Disposal System constructed ( ) or Repaired
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by................ z y-•----------•.............------•--•-•----•------...............................----._......
l / �i f Installer!f
has been installed in accordance with the provisions of T -TL , r j The State Sanitar ode a^s esc ed the
application -for Disposal Works Constructin Permit No. :_�� `?.................... d9.1 V,_,, =--7- � •
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...
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--�---..�:..:... .X9,17
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