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HomeMy WebLinkAboutApp-Permit-Compliance (Not Installed)No. _------- Fzz ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -re;OV►4................. oF..... :............. , ppliration for Dis}1taual Works Tonotrudiun Prrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: -------------G .33...-----•---- -- ...................---................... Location - Address or Lot No. --.._. 1%. T�...............•---------•---------•------•-------.--------------------------•--.....--.. --•.........---..................._........ Owner - Address Installer Address Type of Building Size Lot ....... i.3.,..r.�1..Sq. feet :t Dwelling —No. of Bedrooms ................ .:-;........................ Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures..................................................... .. —Design Flow ............. 110 ..................... gallons per erson e; ---------------------------------------------------- Total dailyflow ................ w�.r ? gallons. Se isank—Li Liquid ca acct .l M allons Length._..iQ6;L Width; ..19.� . Diameter........Depth..1��.. z —No.WTotal Length ....... Total leaching area.A7.Z._Z._sq. ft.{ =na Seepage Pit No ..................... Diameter .................... Depth below inlet.....--............. Total leaching area .................sq. ft. Other Distribution box ( X) Dosing tank ( ) Percolation Test Results Performed ................................... Date......] On—cl-Q7------....... Test Pit No. I ...... :�:..minutes per inch Depth of Test Pit ........ W...... Depth to ground water ...... /'fi.0............ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ s--------•-------------------- ---•------•--------------------------•----------••--..................... - C1 Description of Soil ... j-----G'j-----1�j�.11.---. ......................................•-•-•----•-----•----------------.....-------•-••-----...--.......------•---------------------------•----•----•--•----------•---------- ----•---....--•----•--•---------••-•----------------•-----•---•--............---------•---•-------------•------------------•--•------•-----....-•---....--------............••-•--•-----•---•--••-•-.... Nature of Repairs or Alterations — Answer when applicable................................................................................................ ....----•-----------------------------------------•----•-----•-----......._.....----...---..........•---------•••-------•-------------•---••••---••-------•-----------•-•----••---•••----•-•--.......... Agreement: The undersigned agrees to install the aforedescribed the provisions of.:ITLZ 5 of the State Sanitary Code — ' operation until a Certificate of Compliance has beggi ssue/, Application Approved By. Application Disapproved for th follo ng reasons:_._ Permit No.��_ �'.-------•------------------------------- Individual Sewage Disposal System in accordance with �e undersigned further agrees not to place the system in t board of health. I U ................................ .... .........Y... ..e ---------- ------- --------------- Issued .•- - u•�.�qc�................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �t l .............. oF........... �.1.8 .......................................... Tntifirair of T-amphiturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (N) or Repaired (y) by.................................................................................................................................................................................................... 10T G 3 3 /� K / / ✓ Installer at.... y.. - gl!,c �}. ►!U sT.... I !P[�Tti.-------•.................................. .. has been installed in accordance with the provisions of T�7; .T , ty$ of The State Sanit ode s sc��j, n the application for Disposal Works Construction Permit No._.�...._._^ ____________________________ dated__ ....._..... `.......... /--- -• - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE SYSTEMA WILL FUNCTION SATISFACTORY. DATE........................••----.....................................----......... Inspector THE COMMONWEALTH OF MASSACHUSETTS"' BOARD OF HEALTH .� h ......... oF..........�"I ----- ........ ' FEE...?... Disposal Varks (gurtstrudiatt fautit Permission"rs hereby granted_.. -- .:---=----------•--• ••-- •---_.; .........---_.....................•-•-•--_........ to Consu�ctor . erj , ( ) an `I0divid Sewage Disposal System at ±.E07" ? 3 i�Q1� YENNED Y1I T A�?M©bC ..... Street � (i f l V as showri'on the ap lication for Disposal Works Constr iii; _::____ Dated.__ ._ Board health (�........ .......... ' t .(BOARD OF SELECTMAN - 1581 i, EXECUTIVE SECRETARY TOWN OF. YARMOUTH r SOUTH YARMOUTH: MA 02664 DATE 19 i,-`,,R,EQE1V,ED FROM A '•" ,; FOR 011AMOUNTACCOUNTCASHrani THIS PAYMENT _ E] CHECK '_ iBALANCEDUE -E MB.0. .' .:a%w�,J'� ..J'.nid.�'� .wla+`�.Y .ae.� d� �_ .✓. <- cr".^? ._-, _ ,_•�/ <o".�_.G',' �m �r_:.!s. t _.��r�a/�r��a, 0