HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Disposal Warks Tonshvdinn rrrutit
Application is hereby made for a Permit to Construct N) or Repair ( ) an Individual Sewage Disposal
S stem
at �z........... 5 ----- - -:----- -... _..:.............. 53
• - ` L A ress or Lot No.
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Installer Address
Type of Building Size Lot ---------------------------- Sq. feet
UDwelling—No. of Bedrooms .............. �---_--_-_----_--------Expansion Attic ( ) Garbage Grinder ( )
P-4 Other — Type of Building ............................ No. of persons ............................ Showers ( ) —Cafeteria ( )
P4
Other fixtures -------------------------------- -
WW Design Flow ............................................ gallons per person per day. Total daily flow -------------------------------------------- gallons.
WSeptic Tank — Liquid' ca.pacity....._......gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z 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 ........................
a------------------------------------------------------ •--------- .---------------------------------• ----------------------•------•---------------------------
0 Description of Soil............•.............•-----••-............_.--...---------•......----•-•........------------------...---•------•-•---------•-....._.........-•-.._.................
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UNature of Repairs or Alt% ations — Answer when applicable -./-04V ....1-aGl�---...h�? ----------/ee ?�C3....�Ct��aVr.
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 thA bOad of health.
Sigd...
Application Approved By.- .............
\ Application Disapproved for the following reasons:_
--------------------------------------------•-....r ...--•------•--------..---.----...--
t Permit No.---• -- -• ?'- -------------- - - --
THIS 1,S,.7O CERTIFY,
by-. - -- -- l .... .._.....
l�
(A 0
Date
Issued.........1. ® ...1...... �:1�.t� ....--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Mrrtifirttir ,af (Enutilliuntr
t the Individual Sewage Disposal System constructed ( ) or Repaired (
at............. --•- .... -............. =•-----------•--------------------------.----.--------•--------------.------------------•--------------------•-.-----.\_......
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as de c1ibed Jn he
application for Disposal Works Construction Permit No ------ - _�---------- dated-_---__ _.— .'"...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA UARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
1 Q� ........................... Inspector..... ` .................... .-•........:... ................... .