HomeMy WebLinkAboutApp-Permit-ComplianceFss..�.� THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Works Tonstrnrtion Prrmit
Application is hereby made for a Permit to Construct
System at:
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(k�tet . Locatio -Address
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owner
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Installer
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) or Repair (Kan Individual Sewage. Disposal
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..................... or I... No ..........................................
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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 )
Otherfixtures.-•-•-•-•-•----•--•-•-•-•..........................••-.••-••---........................._...... .
Design Flow ............. ........._:._............_.gallons per person per day. Total daily flow .............. � ...._.,.._.........gallons.
Septic Tank — Liquid' capacity/�0!dgallons Length.... 0....... Width.... -'5 ....... Diameter ................ Depth....4.......
Disposal Trench — No ..................... Width .................... Total Length...............,.... Total leaching area ...................sq. ft.
Seepage Pit No......../.......... Diameter...../.Z.'..... Depth below inlet ...... .......... Total leaching area..................sq. ft.
Other Distribution box (DQ Dosing tank ( )
Percolation Test Results Performed by ......................•--................. ......................•-•--- Date ........................ 0...............
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........................
Description of
.,�j..et.l.�..
• �•• ??>.. �: G.7 G' iii... ---•--------------------------------------------
Nature of Repairs or Alterations — Answer when applicable ................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beqp issued b t b and of h alth.
Sined.......... ...........
Date
Application Approved By ... - -�• ...... to
Application Disapproved for the following reasons: ................................................................. ......... ........... ------------
......................................' -�.�--.........--•----............--------------------•-•-••-------'•••-- '� ^ ............e...............
Permit
.. -
Permit No........ ......---• Issued....... . �-(GI ...-Dat .......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN of YARMOUTH
f9rrtifirate of Tomplittnn
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Installer
has been installed in accordance with the provisions of T]
application for Disposal Works Construction Permit No...,
THE ISSUA CE OF THIS CERTIFICATE. SHALL
SYSTEM WILL FIJNCTI �1 SATISFACTORY.
DATE................. t.s...l.'o....................................
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State Sanitary Co a as described in the
. dated.......... G1Y
STRUED AS -A GU R TE THAT THE