HomeMy WebLinkAboutApp-Permit-ComplianceNo.1 -- 4?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
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Fas.....'. ._..... ......
Appliratiun for Uiupuutti Work.5 Cnunutrur#' tIrrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: ,
..s�..---�..... . ........ ------------------------•--------------...------------------------
c ,.
/`� �a 1I c�Z
�-s Locatiop . Address
--•-----------•----------------------•-
or • Lot No.
--------.....---------------------..................
Own r
Address
.......... s x�.`..[.......................................................................
-----•------------.............................
Installer
Address
Type of Building
Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms........... Ck ..........................Expansion Attic
( ) Garbage Grinder (nb)
Other — Type of Building ............................ No. of persons..-..-.-----..---.-.---.---.
Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------•----.----••----------------------.....-
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 ........................
Descriptionof Soil ................................................ --..................-----------......-------------------------------------------------------•--•-.
•-•-------------------------------------------------------------------------------------------------------------------------------------------------------•••......-- .........- ---.................
Natu a of Rep irs or Alterations — Answer when applicable ....... 1..0 6...... [&_L ,1_SZ i....�6' .V, ......
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 e b rd of health.
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Signed. est^- a"1 °2 �- S
Application Approved By..... _ ...... ..... .......... � ! t •f ...........
Date
Application Disapproved for the following reasons: .................. //......... 1.. .................................... _
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Date
�
Permit No.----c-� . `-- --------------------- Issued--------- ` :.. D ....................
ae
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(irrtifiratr of Tumphunrr
TRIS IS TO ,E�cThat the Individual Sewage Disposal System constructed ( ) or Repaired=+- j"
by--..1... 41�r h..-----• - . - - -- ti -sit ------------------------------- -----•--•- Installer ----------------------------------------------•----------------..----.-.--.------------.-------
[_
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has been installed in accordance with the provisions of TITLE 5 of _The State Sanitary Code. as described in the
application for Disposal Works Construction Permit No.---.-__': _-..._::-I .................. dated--..-- L ....J.r..... - r ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNPTION,:SATISFACTORY.
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iIATF • �� i` .<: � � Tnsnectnr_____---------- ---