HomeMy WebLinkAboutApp-Permit-ComplianceNo... 3ul Town Office Building
58k� P Yarmouth, ,MA 02.16-1634Pl'
THE NWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for 14spnsal Works Tonstrurtiun Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systema g
Lo ion - ddress o Lot No�.%/)
Owner `//�f/� Address
...... .............. -•- G.!---• ...............................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms ............ _........................ E�„tic ( ) (gt-Cpri><rcier ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
Otherfixtures .-------••------•-••-•------••---••-----------•---...••••---••-•--••••--•-----•-••-------•••-••••-•-•---••••-••-
Design Flow ............. 1_____._.......____gallons per person per day. Total daily flow_...... -z-._._ ............... gallons.
Septic Tank — Liquid ca.pacit}�o 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 into. 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 ........ •••-...._.........------•--•--•------------------•-----------•-•-•------------•----•----------._...........•---•--..._..
............................................................. --•------------•---••----------------•-----•-------•---------------------------------------•------...------....•---•---•-••---.._._._....--
--•-•-------•--••••--•••-•---•-••-•-------•---••-•••-•---•--------•••••-------••••••--------••••••----•-------•---••-•-----------------•-•••-•-----•--•--...--•••••••---•--•-••.....---------•-••....
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 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 the b and f health.
Signed_ ._ .-------------••---•••-••-------•--- ----------t----.....--•••-•-
Application Approved By ..... P�+c-r�L' ...................... � � �e !_1�_•...-------
Date
Application Disapproved for the following reasons: ................................................................................................................
.........................................................................................................................................................................................................
Permit No ... Q1.r,? .._..SU—) •---•----•--•-•-•--•--_..... Issued.... 8» 955 __ ate
----------------•-•-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..._.............. OF.................................................................................
Trrtifiratr of Tontlrltaurr
TWIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (y-)
by...._ _lU4- .....---
Installer
has been installed in accordance with t1le provisions of TITLE 5 of The State Sanitary Cn e as described in the
application for Disposal Works Construction Permit No ---- _- ✓( t�______________ dated __...5.111_Q2a_.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector