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HomeMy WebLinkAboutApp-Permit-ComplianceV� "A. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f TOWN OF YARMOUTH Appliration for Disposal Warks Tonstruriiun 1rrmi# Application is hereby made for a Permit to Construct ( ) or Repair Q'Q an Individual Sewage Disposal System at: YY�nQ.:.::3....-------- _ Location -Addressor Lot No. ..... r..i.-ex�M.__ ����..©:4--.'------------------•-----.--.-.----.--- -........---•------•-----------------------------------_•._---•--------......—`vw .............»..... OwnerAddress Installer Address Type of Building Size Lot ............................Sq. feet U Dwelling —No. of Bedrooms ............ 3 ...........................Expansion Attic ( ) Garbage Grinder WO) P4 Other — Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) aOther fixtures------------------------------------------------=---------------------------------------------------------•----------..............---•--------------• d W Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons. WSeptic Tank — Liquid' capacity --..........gallons Length ................ Width ................ Diameter ................ Depth ................ x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ................... sq. ft. Seepage Pit No ..................... Diameter.................... Depth below inlet .................... Total leaching area .................. sq. ft. Z 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........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x-------------------=-------------------------------------------------------------------------•----- ......................................................... 0 Description of Soil....-•-••-----•-------------•----•-•--••----------------------...-----------•----------•...•-••----•---.............------------•-••-----•---•-------•--•------_-•---• ------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------•- Nature of Repairs or AltegLtions — Answer when applicable-. PPO -.14.4... Ft ..........: .C ................................ ......10M----- A ----------------------------------------------------------------------------------------- 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 board of health. Q Signe..... ......--•-------------------------------------------- � : .--' :-1. --•------ Datee Application Approved By--.....?efollo •--•---------........................................................... Date Application Disapproved for t ng re ons----------------------------------------------------------------------------------------------------------------- Permit No.......<_O ".2' _�Ss-....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN of YARMOUTH (Intifiratr of Tomplittnrr 2-5 THIS I C RTIFY vidual Sewage Disposal System constructed ( ) or by............... 0. --- ..-. --.------------------------------------ - ....................................................... Installer at-...-•..•_-_.. �� .......�....�� ...............•-- . has been installed in accordance with the provisions of TITLE 5 of TjState Sanitary Cn le sC application for Disposal Works Construction Permit No.-__. ".2.V............. dated_.....Z.d THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTRU S A GU RAN' SYSTEMA WILL F NC 1 N SATISFACTORY. f DATE.............b - ------ ----• -- - ` 4 .... ....-................... Inspecto ................... Date Repaired A 0d in the --- ---------- E THAT THE