HomeMy WebLinkAboutApp-Permit-ComplianceNo..... . ........ I Fns... '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tontrur#ion 11rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (,l -)"an Individual Sewage Disposal
System at:
.. ....
Location - Address..- or Lot No.
... ...
± .1�- ....................................... _... ----••---........------•-----........................------........---..................
Owner' Address
........................................._.........................-—`-1.�. �1...l�a cah-)--- Ls 1� j�.-----•-•--
pq Installer Address
6 Type of Building Size Lot ............................ Sq. feet
aDwelling—No. of Bedrooms..........�+ta1._A.....................Expansion Attic ( ) Garbage Grinder ( )
p, Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
p' Other fixtures
W Design Flow .............. zld..................... gallons per person per day. Total daily flow........... .......................gallons.
WSeptic Tank — Liquid' capacity.J0aQ.gallons Length ................ Width ................ Diameter .......------- Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area ................... sq. ft.
3 Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date ........................................
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,.a 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........................
a...••-----•••----•-•.......-••-•-----••..-•---•-•-----•----•...................... .............• ........
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0 Description of Soil ----...-•.......................•-•-•---------.........-----•--••-•-•---------.....-----............----•--••-•------------•--•--....---•--••---•-•----•--•--........_..
---------------------------------------------------------------------------------------------------•----•-•.....-----............. --------.....---------....._....------------...................----
Nature of Repairs or Altera 'ons —Answer when applicable..,..i.&,.Q..A4�A7i.v---- .,......./. aoa.... -X14....
....R,ejV.VJ...........................................................•---------------.................................................-•-•----•-----..............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ilTIE 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 the board of
health.
Signed_ ...11
Application Approved By.....Ohefollowi
............ .......
Application Disapproved for reasons:
Permit
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
(irr#if irtt#r of Tout plianrr
THIS IS TO CERTIFY, That the Individual Sewa a Disposal System constructed ( ) or Repaired (t
by............................................................. PJ.� 14,IJ.......l j:��. .tiJ,°'
..............................................-•--.---•--..........---..................
r ' J Installer
at..................................................... ..... AdXA i ........... W........ .:--------•----.--.------------.-..-.----------
has been installed in accordance with the provisions of TIT of T e tate Sanitary Code a descr:
application for Disposal Works Construction Permit No.___.._... "' . ..... -
application R..�.)
THE ISSUA CEO THIS CERTIFICATE. SHALL NO ONST D S A A TEE
SYSTEM WIL �--.71 1 �N SATISFACTORY.71 12
7
the
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