HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH. HEALTH DE.P r
No.....EL.JyLL Town Office Building
UMMY � �2 TT
THE COMM LYMS H SETTS
BOARD Of H E TH
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......... OF ......... 1-s". -----------------------------------------
Fss... ` �
Appliration for Disposal Works Tonstrixr#ion Vrrmi#
Application is hereby made for a Permit to
System at: , / r I/
(kjaj
Type of Building
Dwelling — No
Other — Type
Other
Installer Address
Size Lot ............................ Sq. feet
of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
fixtures
•-•---...---•----------••----------------------•---....-----------......._..............-•---•------......---•----............----------•------.------
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. 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..........
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Nature of Rep' Altera�t'ons — A
Agreement:
The undersigned agrees to install the aforedescr
the provisions of A'ITLZ 5 of the State Sanitary Code
operation until a Certificate of Compliance has been jg�
Application Approved By
Application Disapproved for the f ollo ving reasons:...
--------------•------•---....................•-••--..............•------------•----•--...._.
Permit No....... ?_.
Sewage Disposal System in accordance with
nnee fur, r agree of to place the system in
... ....-- ....
.------------------ - ate
�'
Date
Date
Issued.-- - ...... 1 ---•---•-•-
Date
---------•.--------.-__ —— — — — — — — — — — — — ------ —
THE COMMONWEALTH OF MASSACHUSETTS
-�' BOARD
..........✓....` ".!� .....OF.......,
THLZIIS.4TO
by . J�..o•C.;ic.
at .-- .= ----•---- - =")'.4 ,��-1'
has been installed in accordance with the pr is
application for Disposal Works Construction4Pert
THE ISSUANCE OF THIS CERTIFICATE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ -�2---•-----•.:..... ....................................
O HEALTH
of Tautpliattai`ai'
ewage Disposal System constructed
or Repaired (1--y' '
w-,-----------------------------------------------------
-------------------- ----
is of TT LE 5 of The State Sanitary Code as described in the
,it No._S. `1 ��-------------- dated -------.�?.`. -`-�_3' .'--�--------
SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
Inspector._..Y� r j