HomeMy WebLinkAboutApp-Permit-ComplianceNo ...1.4 .:':.4� f.?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appli rtttion for Disposal Works Tonstrartion f ermit
Application is hereby made for a Permit to Construct
System at:
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k: Address
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Installer
) or Repair ( (%f an Individual Sewage Disposal
--•---» °-'_
...........................`.....1!� ...d ............. »......
or Lot No.
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..----..... D' -Q t...:...In---••�:_I_�lt ......................
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 day. Total daily flow ..................................... gallons.
Septic Tank -� Liquid capacity!.�%!.gallons Length ..... 4 ........ Width ......... ._..___ Diameter ................ Depth ................
Disposal Trench — No ..................... Width ...... ;............. Total Length ..........
Total leaching area ...................sq. ft.
Seepage Pit No ------ J............ Diameter .... i_4i....... Depth below inlet........, .. Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
Test Pit No. I ............. '.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
........-•-•---••-•--•----•••••--••-•-•••--•--•......_...•-••..............................••-.....•--•-•----•...----•
7
Nature of Re airs or Alterations Answer when. applicable,__ � �`fT �../1..___ ..dyy ...........................
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A eemetit : �1t9
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 Compliance has been issued by the oar of_health,,.__,
ApplicationApproved By ....... . .......... -•-- -•................................ ....-•............. ...............•--
Date
Application Disapproved for the following reasons_ ____________________________________________________________________________________________________________»
..............••-•--•-•-•---......----..................•----•----•••-•---...•--.._............_...........-•--•------------•-••-----•-•••---....-•-•••••-•••-•----•--•••--....___...............--••----
"� » Date
Permit No.. I. ................•--......... Issued_ .........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Erruftrtttr of TompltttUrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at.�..._.... .....................5—___d...... ................
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 ...... gZ—. _,_11 Y .............. dated ....... --.R:..............
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... J�.... 7..:. f�. z.:.-•• ...................................... Inspector.... ` /. ��.......... �'� f `� % .``I � ...... ..............