HomeMy WebLinkAboutApp-Permit-ComplianceNo..q . .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
. Appliration for Disposal Works Toustrurtion 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Van Individual Sewage Disposal
System at:
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OLO /J I # L (�oX�r - AIM
.........._••.._ . . . ........ ...................
edwner
. ........................ ...................................
Installer
Type of Building
Dwelling — No
Other — Type
Other
.. . ......... ...........................
°----------------------••--•--•---•----•...
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7� W1 Cbq Address
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Address
Size Lot ............................ Sq. feet
of Bedrooms ............................................Expansion Attic Garbage Grinder
of Building ............................ No. of persons............................ Showers Cafeteria
fixtures
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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 .............. e�-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 ......................................................................................
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Nature of Repair Alterations — Ans3yer When applicable-AP.Q ---------- q ................ ..................
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T IZj 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 b e bo of health.
Sid.............................................................
ate_,
ApplicationApproved BY-- ... ................................. .... .......................................... ......... . ..... Le ..........
Date
Application Disapproved for the following reasons: ........ .....................................................................................................
...................................................................................................................................................................................
--1 Date
Permit No. L-5- - / Y S ................... ��s .....................
.................................... . .. . Issued.........
Date
—^ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(ffrrfif irate jaf T—amplitturr
THIS IS e i
,T_0--qEKTIFY— T�at th Individual Sewage Disposal System constructed
C, L/ r
by. ................... ........................................................................................
Installer
or Repaired
has been installed in accordance with the provisions of TITIY-, 5 of. -The State Sanitary Code as described in the
application for Disposal Works Construction Permit .................... .....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ................... y ..........-----------•... --- Inspector ---• .'/
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