HomeMy WebLinkAboutApp-Permit-ComplianceNo. S L/ �'�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH MAP I—vT
TOWN OF YARMOUTH 1,t. Z5-_- :1'117-
Appliration for Disposal Works Tonsirurtiou'rrmit
Application is hereby made for a Permit to Construct ( ) or Repair D4 an Individual Sewage Disposal
System at:
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cation • Addres � ,�j ��� � q �• � � or Lot No /���
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Owner dress
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.....- - - ---• ........ .._..... ...._. .........
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms .............. ..........._._____._._._...._.Expansion Attic ( ) Garbage Grinder (--' Ah
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixturrees�..----•----------•------------------.----------------•--••---_-•-•-•-----_••------------•-•-----------•--•----------.--.-----•------
Design Flow .................. ............. gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid capacity_.0 00 -gallons Length ..... 4R'�C7 Width ... --�___-..... Diameter ................ Depth ----- 4,�__
Disposal Trench — No. ........ I........... Width....... ...._.... Total Length_?#.� ...... Total leaching area ...................sq. ft.
Seepage Pit No ..................... Diameter .................... Depth below inlet...K.f.......... 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
Nature of Repairs or Alterations —Answer when applicable...., tl' ----.-- ---- ...----•• .5....._.'.: .... �.--••----
f_. + `J-'�e.J� °¢ • �M ed L vet s ¢+ l� L.._..
Agreement : � in j� G L£.4-+.) lf•w� ® �.K- � � 4.� -� 4,, 4� �Uv-� S
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System 9n accordance with
the provisions of TITLi, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' sue by the ar of health.
Signed.... ----- ---............a ...... �1 t/,,
Application Approved B ..........----•----------•...........
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_.. . .....
Date
Application Disapproved for the following reasons- -------------------------------------------------------------------------•-.--.-----•-------------------------
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Date
Permit No..
.-.----/...................•--------.._. Issued---- - -� D ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(9rdif ratr of Tantphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or. Repaired (rso
bY---------------------- -D�4--t`�. v c tib- `� nr Shcw® c r�r�
Installer�... r' J
at .................. :` _ fVii'=.ice.----
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary C de s described in the
application for Disposal Works Construction Permit No..? -----..-- 1!7................ dated-37io I " � .....................
THEISSUANCEOF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEEHAT THE
SYSTEMA WILL FUNCTION SATISFACTORY
DATE.. .....
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