HomeMy WebLinkAboutApp-Permit-ComplianceNo�.''L.S✓
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrurtion Permit LoT, N f o -i
Applicatition ids hereby made for a Permit to Construct (
100
System atL
i Lo{atio Addr
.............. .._... �!R �J`----...............
�C_ ✓ ; �{',, Owner
... Installer
Type of Building
Dwelling—No. of Bedrooms ............... �.:1..........................Expansion Attic ( ) Garbage Grinder (
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria (
Otherfixtures------------------------------------------__.............-----------------------.........__.............................................
V-,4P—C1
or Repair ( ) an Individual Sewage tsposal
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........................
Descriptionof Soil.....------------------------------------------------.............................------------------..................................----......---------......
of Repairs or Alterations —Answer
Agreement: C� 14, ®L_,/�_ , _ / ��v�
The undersigne agre I "st"a7�the a e es99b-
the provisions of TITLE, 5 of the State Sanitary Code —
operation until a Certificate of Compliance has been issue¢
Application Approved B
Application Disapproved
reasons:
Permit No ......... 9_� — LO- ......... _..
dididua Sewage DisposalSy tb`r�9 a�' ance tt-tl kl
e undersigned further agrees not to place the system in
the board of health.
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...........------- --r'ate
A/
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.Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Date
TOWN of YARMOUTH
Tntifirate of Tomfrlittnrr
t the,,,Itltlividual Sewage. Disposal System constructed ( ) or Repaired (t )
Installer
has been installed in accordance with the provisions of TIT of The State 5nitary Co as describe In the
application for Disposal Works Construction Permit No......�. ��:............... dated.........`:... Z ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S'A GUARANTEE THAT THE
SYSTEM WI L FUNCTION SATISFACTORY.
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