HomeMy WebLinkAboutApp-Permit-ComplianceNo... �. ........� � -` EX
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair (&-I an Individual Sewage. Disposal
System at:
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---- Loca ion -Address or Lo No.
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w d Owner Addr
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Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms................rAiXt................. Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures ................. _............. _--------- _____________________......... -.-___--------------------------- ----------- -......... ---•................
._...
Design Flow ............... /&....................... gallons per person per day. Total daily flow .........._�Z.0.................... gallons.
Septic Tank — Liquid capacity_/O.O -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. 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 .......... _.............
Description of Soil ............................
.................................................................
-
Nature of Repairs or Alterations j Answer when applicable .... Q�.-5Ag7 e-- S- _V4VA44 4.._/'�.epic...6.sx .........
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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 the board of heillth.
Application Approved By
Application Disapproved for the following reasons: ..........
Permit No..........�[. J ... .��..._.... • - ._......
to
D e
1 6 //? / Date
/ Date
THE COMMONWEALTH OF MASSACHUSETTS \ 1,
BOARD OF HEALTH
TOWN of YARMOUTH �A ` y
(Irrtif iratle of Tompliattrr
THIS IS TO CERTIFY, That the Infiividly,al Sewage Disposal System constructed
) or Repaired
by ............................................ .... (�! 1S,S (t �/�;........................_.........................
......
��•-� Installefj
at.................ti ►�. 1 aiG t 6--X --•-----____ Q_.%r ` .�hs�c �1 .......
has been installed in accordance with the provisions of TITLE 5 e State Sanitary Code
application for Disposal Works Construction Permit No.. _.�-___ _./9.1
___________ dated......_-l_C
THE ISSUANCE OF THIS CERTIFICATE. SHALLOT BE CONSTRUED AS,A , AM
SYSTEM WILL FU CTION SATISFACTORY.
DATE....................1 :%................................ Inspector..........- % ..
in the
THAT THE