HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
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Appliratinn for Disposal Works Tonstrudion 1rruti#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Systenk
at:
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Address
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Installer Address
Type of Building Size Lot .... 0-/l ssq. feet
Dwelling —No. of Bedrooms ........ .............................Expansion Attic ( ) Garbage Grinder •( )
.Other —Type of Building ............................ No, of persons ---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures--------------------•-------....------....---....-----..........-•-------------------------------.....--------...-----•----...._...._._..........--...
Design Flow ................ ...............gallons per person per day. Total daily flow -------- t3t.3.-10.................... gallons.
Septic Tank —Liquid* ca.paci gallons Length6i-- �... Width- � Diameter ................ Depth_��..—' .
Disposal Trench — No . .................... Width .................... Total Length ............... ..--- Total leaching area ................... sq. ft.
Seepage Pit No.._ ............ Diameter.... .. _ Depth below inlet..... Total leachingarea..,S-S .-sq. ft.
Other Distribution ox ( ) 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...................................•--------........---........•----....-•----•--•------_...
•-•--•----------------------••--.................--••--•---------------------------...-----........-----------------------------------•--•--------• e
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Nature of Repairs or Alterations — Answer when applicable... 16 .......................... ... _____...._._.... .
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Agreement:
The undersigned agrees to install the a
the provisions of TITLE 5 of the State Sanit
operation until a Certificate of Compliance has
/1 Signed.
Application Approved By
Application Disapproved for the
Individual Sewage Disposal System in accordance with
h � undersigned furth not to place the system in
r/ the boaxt 2f hea
Date
�. .. .1L. .�. Date
Permit No....0�~ ...............• Issued......... . �'�.. I--�-- -�- .............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irruftrate of faomptlaurr
b - - THIS IS TO CERTIFY, T � vi u wage Disposal. System constructed ( ) or Repaired (
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has been installed in accordance with the provisions of TITLE 5 of The ate Sanitary C. d as desc . e m the
co
application for Disposal Works Construction Permit No.--...... .--....... dated ........ .... ��"'��..:I..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED S G:UA�RANTEE THAT THE
SYSTEM �IkL F�NCTRM SATISFACTORY � R �
DATE.. ...................... ...................................... Inspector....