HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for 11ispos l Works Tonstrurtion ' throb#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
....... .l�L .G.... F ................. ......_...----.... ........ .D... T . .:a-
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Location - Address n or Lot No.
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Owner Address
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Installer Address
Type of Building Ott �G� Size Lot..4Z , =._..Sq. feet
aDwelling— No. of Bedrooms -------------------------------------------- Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons •----�.................. Showers (Q) — Cafeteria ( )
QOther fixtures ----------------------------------------------------------------------------------------------------------•------•--------------•-••---•----------•---
Design Flow......... _ .......... gallons per personer day. Total daily flow. --..... S.:3 .....................gallons.
Septic Tank— Liquid' capacity -M gallons Length.: �. : 5..... Width._H_-_5_'_._ _._ Diameter ................ Depth...` -1...
x Disposal Trench — No ..................... Width ...... :............. Total Length .................... Total leaching area ....... ;........... sq. ft.
Seepage Pit No ........ . j .......... Diameter ..... 10__......... Depth below inlet ..... 5......... Total leaching area....a 3.5 q. ft.i
Z Other Distribution box ( ) Dosing tank ( )
' '' Percolation Test Results , Performed b ._._ n _....... :� r±._t __.__.__
Y , Date.. =�----- ....
Test Pit No. 1................minutes per inch Depth of Test Pit ..._.t a-..___....._ Depth to ground water.............._.._...... Yb�
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ 8fr'"�'
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Description of Soil .... 6.. _� r(�_-* 3�....6a......h1 � _ 60" _ r4!;�'� ��.
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U Nature of Repairs or Alterations — Answer when applicable ................................................................................................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
` the provisions of i I . IZ 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 board of health.
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'---- ........... Application Approved BY
7:47
Date
Application Disapproved for the following reasons: ....................
Date
Permit No ......... L-'- : •................
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haft
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THE COMMONWEALTH OF MASSACHUSETT
BOARD OF HEALTH V�Ila
TOWN of YARMOUTH
Ter#ifirair of Toutpita i
THIS I CERTIFY, That the I div ual Sewage Disposal System constructed ) or Repaired ( )
by..............5 ��.._..... �.�. .... �... ........:...............--- - -- ..._........ - .....-........_
• . -•-•- .._.
t , n Installer
at] `'.�.... ---•----- -- ------ ------------- - .
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Co(. as de ribe in the
application for Disposal Works Construction Permit No ........ _- / .r,,,�i.. dated... —.. L ..... �^z�--------.-.
THE ISSU NC OF THIS CERTIFICATE SHALL NOT STRUED RA EE THAT THE
SYSTEM W1 �U ION SATISFACTORY
DATE....: . ... Inspector ..........:.... .•-• •••--- • •----•------...... - -- ---------