HomeMy WebLinkAboutApp-Permit-ComplianceNo._e? <—. /(0I Fns.... . tJ
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Toustrurtion jrrutit
Application is hereby made for a Permit to Construct ( ) or Repair (,>6) an Individr� Sewage Disposal
+
system at:
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Location - Address orNo.
Lot
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Ownerd
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.
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 ( )
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. 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------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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........................ -------------------------------------------•------------------....-----............--------------------------------------- ....................... ............................
Nature of Repairs or Alterations — Answer when applicable_ /�Q®._.�....
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/L10® L'P Z'_"/ 3 fE�T S' �� i ... ---------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code— he undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss by e b and
Signe. ..... --------------- =�' -........... at
....._.... .
Application Approved By.-- ..
ate
Application Disapproved for the following reasons: •--•• ........... ......................................................................................... _
Issued_---._..�..."L ....nau- ...
Permit No .... .c...- ...... Dau
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of .YARMOUTH
Trrtifiraie of Touttrlittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired k>-4
,.Installer
= ......--•---•------•--••----... .
has been installed in accordance with the provisions of TITI-B_ 5 of The State Sanitary Cod, as described in the
application for Disposal Works Construction Permit No.-_ _' _.___i�._�.._.___.:._. dated___ _%.. � 9. .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
/C,
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DATE..... .:,._......J�.............................Inspector... = ._..:'