HomeMy WebLinkAboutApp-Permit-ComplianceNo....[..-� FEB.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Warks Tonstrn.rliun f rrntit
Application is hereby made for a Permit to Construct ( ) or Repair (� Individual Sewage Disposal
System at:
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Address / or I ot. No:-
.................... .........•...._ ►(.e,
�. Owner Address .............. - --------
Installer Address
Type of Building Size Lot ............................ Sq. 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 ............................................ gallons.
Septic Tank— Liquid ca.pacity............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 .............. !t.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........................
Description of Soil..
...................................
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N ture of Repairs or Alteratio s — Answer whgg applica�ble..
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 jhe board Ahealtht„,
Application Approved By ----------- ___e"
Application Disapproved for the following reasons:
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Permit No ............. -� ...........
......... W'",
............................................ ----- -• ........ .,
' Date
Issued......................
ate
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trr#ifirttir of Tontlrlinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
s( ..-•--••..----•---•---------•---•---------------------•-----................�._
Installer
at_ ---Q-! .......... �/.2_T`1 e �. t -..P-...... '------------------------- --1�" 1 ..._
has been installed in accordance with the provisions of TITLEState Sanitary Code a des r'beo in the
application for Disposal Works Construction Permit No.__. -----------_.------.- dated ...... 7.1j .__ ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------------`f.-' .:.AF. —.......-----------................ Inspector_..--- --A- - - ----
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