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HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH! HEALTH' U'EPT. No.'. Town Office Building " THE � nY� h 0266 L b M SSACHUSETTS ` BOARD OF HEALTH . .......... ........................._.....O F....................................... APPlirtttiun for Disposal Works Tonstr wit 11trutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal r t System at: .................. ........ •- ---................ ---- - -.. ......................... Lo ' (•`�1.G+L7`�'� n ' _[ � j � der ............ ..... _--...- ---•------•......•-----•-•----•-------•-- ....l...ar{... �.. ill ..._ ..... ......................... :--- .. Installer Address Type of Building Size Lot ............................ S feet Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 4 Other —Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Other fixtures .. j Design Flow............................................gallons per person per day. Total daily flow ............................................. gallons. Septic Tank — Liquid' capacity.._......._.gallons Length ................ Width ................ Diameter ................ Depth ................ i 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 ........................................ i 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 ......................... i Description of Soil. ...---•----•---------------•------•----.•......---------•-•-•---.....--•-•----•------...-•-----•••-•-••-••-•---•-•-•••--••---•----•-••---••-----•---•----.....--•-•-•-- ...----•--•---•.......---- ----•---•-----------------------•------•--------•---•----••------•------•--------...--•----•----....----•--- = > Njture of Repairs or Alterations —Answer when applica le.. �"�b-___ T�----- 1ll� ..�sl�„LfC- ._._.... --a ................ �_r4vn........_z... r- �c�2 .......--.._...--•-•-------•--•--•-------••-----•------••........................•----•---............. Agreement: The undersigned agrees to install the afo " described Individt S wage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitar Code — The un d further agrees not to place the system in operation until a Certificate of Compliance has ee issue y t bo d of lth. .:............ •-- •....... .............. Signe z/ Application Approved BY ... ..fid-- --- •....... ..... ..... -'S, e• •- Application Disapproved for the 110 reasons: ........... Date. ...........................•.....--....................--...................................---......._..---..........•----.......•.......--....---............___..._........... ..•............. Date Permit No..•--•--. e�r2 .._.. Issued.-------.� .�� Date-- / ...._-_.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ .!.0.1/X1 .......... OF ......... ..Q�........................................................... Trrfifirtttr of Tuntplitturr THIS IS CNTIF�Y, ThpLt the Indiyldual Sewage Disposal System constructed ( ) or Repaired by, .. (� �r�l�f��L U' --------•-------- ------ - •- (� / d-� lG?r/ /K.o��Llo has been installed in accordance with the provisions of TI P Sof The State Sanitary Code as described in the application for Disposal Works Construction Permit -------�--•----------. dated------�-...-���--•-----�............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................•----------........---•--------•----------........----•-....--- Inspector ........................................................ -- --- -- ------....._._