HomeMy WebLinkAboutApp-Permit-ComplianceNo............... . .:..... Fzs.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrur#ion ramit
' Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
system at :
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L 'on - Address
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o.........................
....... .. _..__ �°
c..�4i)- 1' ------------------------------------------
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling— No. of Bedrooms ..... --------------------------------- Expansion Attic ( ) Garbage Grinder
Other — Type of Building --------------------_----- No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixt es.........-•----•------•--------•-••-•-•-•-•--•••----------------------------------•-•-----•-•--•-----•---•-•••------....--•-....-•-•--....-•-•-••....
Design Flow ......._.`_5. .....................gallons per person Xr day. Total daily flow..... 0 ........................ gallons.
Septic Tank 4 Liquid Length..? ......... Width..S ......... Diameter ................ Depth ................
Disposal Trench — No. '�:_. Width .... 9............. Total Length..3.60 f-------- 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 ........................
Description of Soil ................................................
.................................................................................
Nature of Repairs or Alterations - Answer m
Agreement:
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The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has $beenid by e b health.
Sed..-• -----------------••-•-••......•...--- -- --
Application Approved By--- •--------' •-•-•----••------•• -...2 t^g�Date
Application Disapproved for the following reas-----•-------.....------.......----•-------------......------------------•--•---•-----••---•••..--••-
...--•--------•--------------------------------------•-----------------.........---------------•-•-----------••---•--•-•---•-•-•-••• ......................................
Date
PermitNo......................................................... Issued-------.......-...-..--�-•-....s----------
Date
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THE C.OM-MONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(Irr#ifiratr of Toutphaurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by-------------------•-•---------•------UOA)A€>. ....... LQat-K- -r..------------------------------.....---•------------------•---------••-----...----------•--•--------•---
Installer
at--------------------- .........-�,f .n:)-L�S-..... n oe----------------_-_---- `!�a....\0111111160_6 ----------------------------.----
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
appslication for Disposal Works Construction Permit No._`L_S�`_Y 1_ ___________________ da.ted_-- _"� 'Y j__. .................
.THE.ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUE® AS RANT HAT THE
SYSTEM WILL FU CTI N SATISFACTORY.
5" �a
DATE ................ ----- Inspector--CIA'OT�RIJED AS
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