HomeMy WebLinkAboutApp-Permit-ComplianceNot�C(.• Fizz ...... .$1:5.00.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. Town .............. OF ........ Yar mau th......------.............................................
Appiiratiun for Disposal Works Tonutrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair tcx ) an Individual Sewage Disposal
System at:
ti....... Yl. ... Ya rmau-th....-•-----•-•---•--
7---------------•.................--•---...---•.....---...................---...
Location - Address or Lot No.
Mr. Marls_-• ....................................... Barbara Waltham Ma. 02154
.... ... ....----•• -•--.-.195--.-•--- ---•-•-----•-R- .d. -..- ---•----•---•m ................... .... 4..------
---
Owner Address
W A & B Canco350 Main St Wt___Yariuo�ililh,_-,MaR...................
-------•-----------------------------------•------•--------------•------------....-----------..... .....--•-----------•••-.•-_.. :
Installer Address
14 Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms.................3
........................... Attic ( ) Garbage Grinder ( )
'_lPI Other —Type of Building No. of persons ............................ Showers Cafeteria
( )
P4 Other fixtures --------------- --•--------------•-----------••-- . .
W Design Flow-------------------------------------------- gallons per person per day. Total daily flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No --------------------- Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z 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 ........................
(i, Test Pit No. 2................minutes per inch Depth of Test Pit ---- ................ Depth to ground water ........................
---------------------------------------------------------------------------------
Descriptionof Soil ................................................................................... --------
.----------------------------------------------------------------------------------------------------------------------------
---•----------------------------------------------------------------------------------------•---------------------------------------------------------------------••-----------.....----._...--•--_.....
Nature of Repairs or Alterations — Answer when applible_1_ QQ.0.. -gallon th..D"13ox..
............ azxtl__ 5QQ- -..g
P
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee.�e� by,.the board of health.
Application Approved By.
Application Disapproved for the following reasons:...
Permit No...�
�Datq,
Date
---------------------------•------• .............................
Date
s r
Issued ..... .-------•----------------
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... T(mn........ OF ........ yartao.rh............................._...................._...
Tntifirate of Emplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired Sac)
-B
by ---- ik•-$�•- - Cancv-------•--3-5E?"Ma1 h' -Sr,- ------------- Ninii�artnou�%�'= 1---------------------------- -............ ..--------------------
at----- ?--,Cand1teW0Vd--Rd-------- Ww- M.M.W --------------------------------------- Mark --- Budrem ................................................
has
- -----------Mark---Audrem---------------•-----------------....---------
has been installed in accordance wrth tie provisions of TITLE 5 of Tie State Sanitary Code d cribed in the
application for Disposal Works Construction Permit No ---- �r'__-tel .............. dated ---- �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RA TEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY. 00
DATE../_v" . i?'�'� ................................................... -------------------------•------••---- Inspector..._.