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HomeMy WebLinkAboutApp-Permit-ComplianceTHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF YARMOUTH Application for Disposal Works Tons�rixrt'on rrrmi# Application is hereby made for a Permit to Construct ( ) or Repair " an Individual Sewage Disposal Systemat • ---..._...q................................ -- If - Address Owner ---------z. -.................................................... Installer Type of Building Dwelling — No Other — Type Other ..... • --- ----------_.........--•- -- --= Lot No. -•-•-----•--..... 47 Address ss 1�....................................._...-•.......--•---................ Address Size Lot ............................Sq. feet of Bedrooms......................................Expansion Attic ( ) Garbage Grinder (Z(, 6 of Building ............................ No. of persons .......................... .. Showers ( ) — Cafeteria ( ) fixtures Design Flow ........................... ............. ...g< Septic Tank — Liquid ca.pacity..........ga Disposal Trench — No ..............:.... Wia Seepage Pit No ..................... Diameter.... Other Distribution box ( ) Percolation Test Results Perform Test Pit No. I.................minutes i Test Pit No. 2................minutes per ............................................................................................................................... IIon per person per day. Total daily flow............................................gallons. on Length ................ Width ................ Diameter ................ Depth ................ .................... Total Length .................... Total leaching area .................... sq. ft. ............. Depth below inlet .................... Total leaching area .................. sq. ft. )o 'ng tank ( ) by----••--••••.._..-••--•--------•.............................•---•-.._.. Date ........................................ inch epth of Test Pit .................... Depth to ground water ........................ inch Depth of Test Pit .................... Depth to ground water........................ •------•...............................•---••••••------•----------------.................................... C ofSoil .............................................................................................. ..--•-----------------------------•---------------------------------------------------------------•----------------------------•- Nature of Repairs or Alterations — Answer whe applicable. /Jr.r___U-�' �... w _ _____._.. ?_`_�, o................... ........................................................... �. !�.a•_.lN t - ........-------------------•--• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in o g boa of health. operation until a Certificate of Compliance has been issued b P P Y the bo Sined... . �- �!}--....----••---•-----•-•--•-• ---•--------•-......------.... Date Application Approved BY .. __ = .�--...... -•----- Date Application Disapproved for the following reasons: ............ ................................................................................................ aC, r . te PermitNo....................................................... .. Issued- - --------------- 5 ...... a......... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH Trrtifiratr of TottwItancr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (✓f by------------------------------------- ........ `:.. .... -...-.-.----------•------.------..---•-- -----------------•-------.----....-----------------.-.-----..---•-------•-- C ` ` Installer —r— at- 1 , - (` .........! .......... - ------r••---.....••---------•------•.............................•---.......------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__`fS�::__a:UG------------- dated_...�-..�1_-.�.�..........-...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE i _ SYSTEM WILL FUNCTION SATISFACTORY. _ (% DATE.......................................��................•---------------- Inspector--•-- f��1� ?:c::: L�-- ---