HomeMy WebLinkAboutApp-Permit-Compliance'-7 ?
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Aupliratinn for Disposal Works Tons rur#inn jkrufi#
Application is hereby made for a Permit to Construct ( ) or Repair IX) an Individual Sewage Disposal
System at:
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Location - Address r Lot No _
1 �...T.Id.... Y. -AI ALC :............•---•--•--•------- 1k.Z7.F.f�tY. f3P................
Owner �_ Address
., .._C.rz���` ....----,7. !?��' z. l.. l.S .%S�Z?....Yr9� ,r r�T ...................
Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder (X) IVO
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. 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 ........................
Description of Soil .........................................
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Nature of Repairs or Alterations —Answer when applicable../to00.._(01_".9//'&&.._.� _}__ /.� s. ........
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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 „e by the, oar f i
Signed... ----- . ------ ---- • ------------------------------------------ 4 ......_1�.._
Application Approved By--- ...... ------------------ --- --- •.............. ............... ...........--.. �?ate..�.Sr
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------•-------.........---------------.._
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e�<— I ? 3 r Date
PermitNo ...... .l..J............................................ Issued.........�)..:i./...2.�...1. .................
D
T THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
Trrfifirate of fanutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (A
by .... .�...... .6-L-? S- l..,>..------a.........�.r..e:: ! _.l ✓ ::. �= .�'::! * ?!,c_ c._ ....` . ------ -
Installer
at_f .._ Z c F' l '✓7 ..C.�!C'!..!?t. - - --------................................................................................................
has been installed in accordance with the provisions of TIT IF,, 5 of The State Sanitary Co e a described in the
application for Disposal Works Construction Permit No.._. -_55_.x..1-7--.3 ................. dated._.. j.���1 �'.......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE.........:. ................... �� �............................................ Inspector_.. _' . � ------ __.........................