HomeMy WebLinkAboutApp-Permit-Compliance7 �
THE COMMONWEALTH OF MASSACHUSETTS51
BOARD OF HEALTH way caa 1
TOWN OF YARMOUTH
Applirttiion for %powd Wurktt Tortsiruriiun Frrmii
Application is hereby made for a Permit to Construct ( ) or Repair (U an Individual Sewage Disposal
System at:�
...................................... ..........................1 0l.. L.:.......... .......
Loc tion -Address or Lot No.
.kr ta.
Owner Address
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......... -.. .. ...... .,?.........�z4?.t`J: ........._SDw� c 171:.........
.................................. .................
p� Inatalier � U '> j �JI-=-v�. Address
6 Type of Building Size Lot ............................ Sq. feet
aDwelling—No. of Bedrooms .............................. ........... —Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ... ..L .................. . Showers (Z — Cafeteria ( )
Other fixtures ............................
Design Flow............................................gallons per person per day. Total daily flow .......... .................................. gallons.
WSeptic Tank—Liquid capacityJ,0..2egallons Length .............. Width... ...... Diameter................ Depth:?::G. 1-7_
Disposal Trench — No ..................... Width .................... Total Length .......... j........ Total leaching area .................... sq. ft.
3 Seepage Pit No.....�.5i-..-.--„ Diameter .... .7 .............. Depth below inlet................ Total leaching area .................. sq. ft.
Z Other Distribution box ( )— Dosing tank ( )
Percolation Test Results Performed by.... ...................................................................... Date ........................................
`Ij 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........................
A+'---•----.--....--.---•-----------............................••-----------•................_..•••---..................................................
0 Description of Soil.............................................................._.................----.... •---...................•-•-------•----.....................................
w........................... ........ ...---�.....:�............................... .............. ...............
U Nature of Repairs or Alterations —Answer
w..hen a plicablhet;.!.:.T5uJAY...
..( %
......................
.w•l• iJ�...2....... ............. ..:................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLF, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issuedbyby the board of health.
%
Signed... -? ....k .fit 2.P ...................................
to
Application Approved By... ............ ....
ns ..... ....D..a:.t.e
.Application Disapproved for the ........
............-
.........._..
...................................................y....................................................................................................... ......................Date .............
Permit No........L.......&.7......................... Issued.............. ` . 3......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
fUr#ifirttir of fanmplitturr
THI,F IS To CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
has been installed in accordance with the provisions of tTLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._."t.......... r1. '............._... dated.... G/...:..l.:.r1.......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED.AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
P r.l ii
Inspector.,.DATE... '......................................
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