HomeMy WebLinkAboutApp-Permit-ComplianceNo...�---�...... .l... +�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonoiruriion rlermi#
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
.'�!.._..T .0 l € laJ►/ ._ L - -...- •......... .............. ----- 7.... i l .....(�. ...-..
Location •Address -----•••---------------------------------- or Lot No.
........................1 .. ?.e.......................................... ..............................................
Owner Addres
Installer Address
Type of Building Size Lot ............................Sq. f ek
Dwelling —No. of Bedrooms................�- ............................Expansion Attic ( ) Garbage Grinder to
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures------------------------------------------------------.----•-----•-----•••---•---•--•--•-••-••------------•-•---•--••---.........-----•--•----•-------
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 ............. ..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 ..........................................................................................
........................................................................................................................................................................................................
Nature of Repairs or Alterations - Answer when applicable........,) �1. _l1_.._ 1 _L._.__7-�9` ___-____�r......P--
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 boar f health.
Signed..'�?--'Z*i! - '.............-•`------•-••-•-.. ... .•..........�...... . . ....
Application Approved By... — � je--q
--•------- 1--•.....I -k--•-•----- ----
Date
Application Disapproved for the following reasons: --------- ................ -------•...--•-•--•----•-------••--...-----•--------•--•-•-------------•-----.......
........................•---......-----••--•--------.....---•-------•-•---...-------------•----------------•-----------...----------------------...------------.................. •--••-----•-------•----
Date
Permit No.-----9-I•" 10.....---•...................... Issued------...a�......
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrlifirate of Tontpliatty
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (,k)
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nstaller
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has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
i
application for Disposal Works Construction Permit No._.,?4__:/6..................:... dated--..--:..7 _'.lf _ _..% ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE S A GUARANTEE THAT THE
SYSTEM WIL FU �CTION SATISFACTORY.
._----------- ........... . ...•- Inspector-_
DATE —
1 .....................