HomeMy WebLinkAboutApp-Permit-Compliancey5.
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No.80 ...... 9,!.l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................... T.own..... O F....Yaxmouth.._..........
Fms.....!10 ..00
Appliration for Dispooat Workg Tonitxnrtion Prrnnit
Application is hereby made for a Permit to Construct ( ) or Repair ( x ) an Individual Sewage Disposal
System at:
BQ�Ith.Xaxmouth_.D26J?T�--.-•--- Map
Location - Address or Lot No.
Charles..Qwejao.................................................................. ....... ------
Owner Address
A.&..B Cesspool -Service ...................... 128 -.Bishop __Te ��e....HY x4x1 S,---...Q260I ---
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling — No. of Bedrooms ............. 3 ............................ _Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons_.._.._ 2 .................. Showers ( ) — Cafeteria ( )
Otherfixtures-•-•----•--------•--------•---•--------•------------•- -•-------------•--•--•----•--------•-------•---•-------•---------•--•--------------------------
Design Flow -------------------------------------------- gallons per person per day. Total daily flow -___-__--------•----_-__.._•_--_--------gallons.
Septic Tank — Liquid capacity ............ 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 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. .......................
Description of Soil ------••-------------and
-••--------------------------................... -------•-.........................................................
---------------•-------•-----------------•---------------------•---------------------------....---------------------------------- --------------•-----------------------•-•--------------•-••---••••----
--------------------------------------------------------••------•-••-----•---------------•------------------------•---------•-•-----------------------------•----------------•--••-----•----------•----
Nature of Repairs or Alterations — Answer when applicable ._-___inatallatiDn... af-•1... fLawdif ussar,---pre-jaa.st ,
stone._paQk d..Wit11.1Q---ton...Qf---st•e1-Le-•---.(.Qy_erf1QW)--•••-----------------------•--------------•------••-------•--------•••----------.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT:. -
5 of the State Sanitary Code —The undersigned further agrees not to place the system in
operation until •a Certificate of Compliance has been 'ssued by the bo r th.'
Signed---------- --• .-• . --- --- .... ......-.1-Q/1.44aQ---•-----•-
Da e
Application Approved By ... R'.... ------•-.
---• ....•...--------•-•--•••---•---•-------•--------•--------------- 10��4 _ao...........
Date
Application Disapproved for the following reasons-------------------•-----------------•---•---------•-...........................................................
.......................................................... ------•----------------••........--------•---------•-----••-----•--------•------•-----••--------------••.............................
Date
80- �S� 10 l4 80
PermitNo--------------------•--------- ----------...------------- Issued_---------------------�-----�•----------------•-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................Town........ OF........ YarM.OUt h ..... ..................................................
Tatifiratr of Tontplianrr
THIS I TO CERTIFY That the j 'ividual Sewa e Dis osal S- stem constructed ( ) or Rep it a ( X)
A & Cesspool Service, ]� Bishops .Ierrac�e, Ii annis, 1�% 02601 - 775-12
by------_-------------- ... y_.. - ...............................
41 Sea 'View Ave . , South Yarmouth,. MA Insd!8 4 - Charles Owens
at----------------------•-------------------------------------•-•--------------------------------------- ------------------------------------------------------------------•----------------------------
has been installed in accordance with the provisions of TIT ` of e State Sanitary Cod as
l,I- 0 ed in the
application for Disposal Works Construction Permit No ----------- ... ................ dated --------------- t...__l__-._____--.._.-.......
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT FS STRIIED AS A GUARAN THAT THE
SYSTEM 1AlILL FU CTIO SATISFACTORY.
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DAT". `r5�17...................................... Insnec . ....... •. ... •. ..... -- ...... •......................................