HomeMy WebLinkAboutApp-Permit-ComplianceNo. F$s_......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appl ration for Disposal Works Tonstration lierniit
Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal
System at: � � �� G,�-- 59
................ _. .........T ..._. .. .. .......................-------..... ............................... .....................
Lo
Location -Address ............... Ge or .............................
-.- own r -•-• . 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 ( )
Other figures
�� .. .
Design Flow ..............
.-......_ ..................gallons per person per day. ToW daily flow............................................ gallons.
Septic Tank J Liquid capacityl(7,0 allons Length............ Width ................ Diameter ................ Depth ................
Disposal Trench — No ..................... Width ..................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ....... 1............ Diameter..... ... Depth below inlet ..... L. r........ 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
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Nature of Repai s or Alterations —Answer when applicable_.:;:. _.. ........ ..........
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 furtlier agrees not to place the system in
operation until a Certificate of Compliance has been h board oaf_. W
Application Approved By....
Application Disapproved for
.�....w:. -------...:.2_: .i..
Date
- ........ .......... 3:::L _ .3......Date
..
following rewonsf ........
Permit No .......... Y :r. .•-••----•-......-•---
THIS IS.TO CERTIFY,
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........................... ........... ..........................
Date
Issued ......... .
. ...�
Daft
7............. —
Da
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrtif ratr of Toutplittnrr
the Individual Sewage Disposal System constructed ( ) or Repaired
.................................................................................••......
v-
at ..........................................
�r'�. ..... ._....:.........._............_ .............. -• -
has been installed in accordan a with the provisions of TITLE � of The State Sanitary Code /as,4�escribb d in the
application for Disposal Works Construction Permit No ........ ... .. .� ._ .... dated..........j THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE GANSTRUED AS'A GUA ANTTHAT THE
SYSTEM WILL FYNCTI?N SATISFACTORY. � �
DATE..................... �.i >.:�1................................. Inspector................. .......:.................. j ....................