HomeMy WebLinkAboutApp-Permit-Compliance�V.pun
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THE COMMONWEALTHOF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Disposal Varks Tonshwflan rtrntt#
Application is hereby made for a Permit to Construct ( ) or Repair Q,/�_ an Individual Sewage Disposal
System at:
LOT- L5
---...-- -------------------.......... ...--•----.r_.........P.._.:
ocation - Address W �. r I of
.....oAA?S l:� v.. s ��:ri��__...............--•..................--_...
Installer
Type of Building
Dwelling —No. of Bedroon
Other — Type of Building/
Other fixtures
--------------•-. Address
-------------- iVAKw •- ..._------------.............._
----- - ----
Address
Size Lot____________________________ Sq. feet
___________ ______________Expansion Attic ( ) Garbage Grinder ( )
o, of persons ............................ Showers ( ) — Cafeteria ( )
Design Flow .......................... --•-•fme
Septic Tank — Liquid ca.pa ity..sDisposal Trench — No..................Seepage Pit No_____________________ Di.__.Other Distribution box ( )inPercolation Test Results ._.
Test Pit No. 1 ______________ minutes per inch
Test Pit No. 2................minutes per inch
r person per day. Total daily flow............................................gallons.
Length ---------------- Width ---------------- Diameter-------......... Depth ................
..__..._._.. Total Length .................... Total leaching area ................... sq. ft.
.___ Depth below inlet .................... Total leaching area .................. sq. ft.
tank ( )
-------------------------------------------------------------------- Date ........................................
Depth of Test Pit____________________ Depth to ground water ........................
Depth of Test Pit____________________ Depth to ground water ........................
-------------------------------•--•-------_._.. _.._....--------------------------
Descriptionof Soil--------------------------------------------------------------------------------------------
------------ ------------ ----------------------------- -----------•-•--•......... ........ .............. -------------_•---- --
Nature of Repairs or Alterations — Answer when applicable._`__ 90
-------------•---...--------•-••----...-----•-•-------.._....._..........._..._......•----------•-----.. V".0 _..._.. ....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 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.
Application Approved
Application Disapprove
Permit No .......
1 �_.:1��..::
,_._._
a
..�lo DEQ
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
fgrr#ifiratr of TOMplittnrr
THIS IS TO Com? . That thf ndividual Sewage Disposal System constructed ( ) or Repaired (�
by............................ , . ZI ...(.... ......------- _--...._..------•-..........---._...---------•-----.....---------- .......--------..._
has been installed in accordance with the provisions of TIT 5 PfState Sanitary Code , ,{l Ir'bed in the
application for Disposal Works Construction Permit No ........ ."".� he ........ dated ........ t ..:...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAR N E THAT THE
SYSTEMA WILL WONOTION SATISFACTORY
DATE.. _ =t ..... - - Inspector...' _..'..... ...........
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