HomeMy WebLinkAboutApp-Permit-ComplianceYAR;MOUN HEALTH DEPT.
Town Office Building Fss.....�
THE C AN RLYA� M/�SS�G'1-fU�SETTS :�
BOARD OF HEALTH - L
- ........................................OF .........................................
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Appliration for Disposal Works Tonsirnr#ion 1rrnttt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage DisposiT
System at ja
��A, _/ at�� dress -------------- / or Lot No. ...._......
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o _e------ Q 7� % _r ------------------------------
, /-1- c� S ... ...........
1l Address
Installer
.............................................................................
A- direre"ss -----------------------..........-----•----
Type of Building 2 Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms ........... 3-----99Epa sio A 6 ) Gar- )
Other — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures..---•------...-•-------------------•--•-----------.........---------------•---•------------------------.........----................................
Design Flow........... &15a.....................gallons per person per day. Total daily flow........ .3d ........................ gallons.
Septic Tank —Liquid capacit/A?4?egaRons 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 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 ........................
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Description of Soil----.� _G? !9S!- ----• `'`�4� .................................................
.............................................................................................................................................
...--•-----------------------------•---------------------•---------•---------------------••-------------------------------- ................
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 TITL% 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued by the b,,IIoar of health.
Signed.... ............ .......0�`
Date
Application Approved By..- tll? �- ----------------------------- .....51.k..1 D -------•.---
Date
Application Disapproved for the following reasons:---••--•------------------------•-------•--•----------•------------•---•-------•----•------•------•---•.........
---------------------------•------------------...--------------------------............................-----------...---------•-------•------------------•-------•---......-•-•-•-•-•.....
Permit No ..... `S. lit 1p...--------•-----•------•• Issued -----.. 5. �. 0.. 5 --....... Date ......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... 00 ................................................................................
Trr#ifiratp of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (t%
by---•--j-.it�------------------------------•-----••-•-•------------------.-.--------.-- -----------.--.--------.-.--.---------•---------------..-----....-.-.----------.--••---•-------
Installer
at..... _!Ku ,> •� _ 1 °� ,---------------- ---------.--------------•---••----.......-------•--•--•---------------------•------................------
has been installed in accordance with the provisions of TITL 5 of The State Sanitary CodF. as described in the
application for Disposal Works Construction Permit No._�`.� -.�1 A LQ .............. dated__... g_.�4..1_� S . .................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector