HomeMy WebLinkAboutApp-Permit-Compliance��� �� YARMOUTH HEALTH DEPT.
No............ .............. 1146 ROUTE 28 !6"
F
SO. YARMOUTH, MA 02664 ps........._:_^ .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliratinn for Din Tonsirnr#inn Famit
Application is hereby made for a Permit to Construct ( ) or Repair O an Individual Sewage Disposal
System at:
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------------------------
nn cation - Addr ss r I of o. /l
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Owner A dress ' /�
..
Installer ess
Type of Building L:_ Size Lot ----------------------------Sq. feet
Dwelling —No. of Bedrooms ---- _--.---_-----v---0 ------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ----- ---_-----_-------- No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures .........................
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 ........................
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Descriptionof Soil ...................................................................................................................
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Nature of Repairs o, r` Alterations —Answer when plicable__ KGszey nQ,_c.2xjsz t t /a.-,ug,��P_. (C.. 5
ZDja ny-- Q�a_ '1_�..G S_.tom _ ira ,. l
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Agreement: 1cAw�-Scir�� ST�2`
The undersigne?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 b the board of health.
Signed.. ...---------------••------------------ -•-6-'zE:.:•8r_..-•----
Date/��'
Application Approved BY ---------------------------------------------- 5 a {
`Date
Application Disapproved for t e f ollo g reasons------------------------------------•---------------•------------•------•-------•-•---•--------......-•----------
.....-------•--....•--•---•--------------------------------------------------------------------------------------------------•-----•---•-----------------...---•-••---............
Date
Permit No ...... 8---- --------------------------------------------- -------------------• Issued_------ .
Z�
--•----•------.... ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
�ku BOARD OF HEALTH
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............. OF...rr)i'r.4s-!.4....................................................
�rrtgfir��le of f�.um�rlittnr�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constrllcted ( ) or Repaired Q/_ )
by.........................
........................................................ --•------------•-----•-•---....----•----------------------••--•----........•---.....---••---.--
Installer
at. -- ------------------- ----•---•----•---•--•---••------------------------------•-•-----•------------••-•----------.-------------_.... _............
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary C110"ae as described in the
application for Disposal Works Construction Permit No.... ............ ..................... dated ......... ...................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---••------•--•••..............................................•--•--------_.... Inspector --------------------------------- ...................................................