HomeMy WebLinkAboutApp-Permit-ComplianceNo...Fxs..... %g':.; .�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliratinn for Disposal Works Tonstrur#inn 11trutit
Application is hereby made for a. Permit to Construct
System at:
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Location - Address
N.r.-'..........................
Owner
.A..0 _Aj ..... .................. ..........---------------------------
Installer
Type of Building
Dwelling — No.
) or Repair ( ✓j an Individual Sewage. Disposal
-------------------------�"T....� o:......!!°°r?, 'g ........or Lot ..
A
'r's
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Address
Size Lot ............................ Sq. feet
of Bedrooms ......... _ryWP.......................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures---------------------------------------------------------------------------------------- .............................................................
Design Flow ............ //._Q ........................gallons per person per day. Total daily flow ................ A 0................gallons.
Septic Tank — Liquid capacity./-OCO.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. I................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........................
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Descriptionof Soil--------------------------------------------------------------------------------------
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Nature of Repairs or Alterations—Answer when applicable...iC.. ...... 1`APLi... 46mr...........
�C?isi - c--,.... .:..- .........................................................................................
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 by the boar4,of health.
A _ %' I I
Signed.
Application Approved By
Application Disapproved for the f ollowAtg reasons :.........................
PermitNo ............... - - '..._........ .............
3 �a . ............
Date
..........................�.............�-----------.......---...
Issued-.... Date.....
Dzq
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Tnrtifirate of Toutplianu
THIS IS TO CERTIFY, That the Individual Sewage Disposal S7stem constructed ( ) or Repaired ( v)..
by.....................................................................a..G..k....---------......-•---..............................--------............................................------.
Installer
at--------------------------------------------------------- ll.. Et�.& !4 4R ......... I/A.4�47r...........................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary C des described in the
application for Disposal Works Construction Permit No.....` 3 :.�'?.................. dated .... �'�`�.5...........................
THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WIIILV FUNCTION SATISFACTORY.
DATE........... � ��............................................ Inspector... ...... .. ...................................