HomeMy WebLinkAboutApp-Permit-ComplianceNo. _.....
THE COMMONWEALTH OF MASSACHUSETTS J#5:�j
BOARD OF HEALTH
TOWN OF YARMOUTH
Applutttion for Disposal Works Tonstrudion f amit
Application is hereby made for a Permit to Construct
System at:
........................
ro—c - on Address
....:1..,___....:..N...D-...-••••.....................
n,� �/j Owner
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Installer
Type of Building
Dwelling —No. of Bedroo
Other — Type of Building
Other fixtures ....
) or Repair ( [�/ Individual Sewage Disposal
..--•- Address
..^+•u ---.- .r >�.................................„............
Address
Size Lot ............................Sq. feet
..........................Expansion Attic ( ) Garbage Grinder (1UV
....... No. of persons ............................ Showers ( ) — Cafeteria ( )
Design Flow.........................................g ons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity......... Ions Length :............... Width ................ Diameter ................ Depth ................
Disposal Trench — No . .................. I ..........:......... Total Length .................... Total leaching area ...................sq. ft.
Seepage Pit No ..................... D mete ......_........... Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosin tank ( )
Percolation Test Results Pe ormed 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........................
Descriptionof Soil ................................................................................................
W••-•--------------------------------------------------------•-...............------.......----•-------...............................!�.�
U Nature of Re airs or Alterations Answer when a licable� & •J'..... f� %� JB..--._..-•..•.....-..-.•
PP ....................
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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 b the b rd of health. 1
Signed..............7 /
. •------------------------------•--•-•----........ ......
,,nDopte
ApplicationApproved By..... ---• ._. •. ....... .............. -.................................. ............................ j..
Date
Application Disapproved f the follow* g reason:........................•-..............------....-•------...---...-----.......------...---•-------.............
................ .......... _�__ Date .........
Permit No......... �% _ ........................... ..... Issued............ % .s�.�.... �-............
Date
THE COMMONWEALTH —OF MASSACHUSETTS
BOARD (OF HEALTH''
4
TOWN of, YARMOUTH
farrufiratr of Tompltaurr
THIS IS. TO CER"Y, That the Individual Sewage Disposal System constructed ( ) or Repaired
by........................................! `......at"I rl...... C144...................... ........................................................................................... ..
Installer
�------' 114nPL, .......................................•--------•-•--
--------- — -
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as describe the
application for Disposal Works Construction Permit No..... '.a.��......... dated.. .:./. $ ........
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION WSATIfACTORY.
DATE. •.9�.`..�-•............................... Inspector....._ ..._. ... -