HomeMy WebLinkAboutApp-Permit-ComplianceYAKIVIUU l n , i1..nw' ' -
1146 ROUTE 28
No---------------- �� S0. YARMOUTH, MA 02664 Fics..... �......
THE COMMONWEALTH OF MASSACHUSETTS
�
BOARD OF HEALTH
i 2- F
Appliration for Disposal Works C>z nstru.rtton f rrmit
on is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
S tem at •
.. , .._..... �=' ..............................
Insta��er
Type of Building
Dwelling —No. of Bedroo
Other — Type of Building
Other fixtures ....
Design Flow. ........................................... gall#s 1
Septic Tank — Liquid capacity ......... ...gallo s
Disposal Trench — No ..................... W At _...___
Seepage Pit No ...................... Diameter .... ........
Other Distribution box ( ) osi
Percolation Test Results Performe by ....
Test Pit No. 1................minutes pe ' ch
Test Pit No. 2................minutes per inch
--------------.. = <.10 -------! '!:W--=--'4 ..................
(ZrLot No.
.......... �t. _..... _..... .....------•-------•.............................
-..1I�'�t mss----•---•----------• .......................
Address
Size Lot ............................ Sq. feet
ion Attic ( ) Garbage Grinder ( )
......................... Showers ( ) — Cafeteria ( )
-----------------
rso r day. Total daily flow............................................gallons.
en h ................ Width ................ Diameter................ Depth................
........ Total Length .................... Total leaching area -------------------- sq. ft.
Dept below inlet .................... Total leaching area ........... :...... sq. ft.
tank ( )
-------------------------------•----._.....---------------.......... Date.............------------------.........
Depth of Test Pit. ................... Depth to ground water ........................
Depth of Test Pit .................... Depth to ground water ........................
Descriptionof Soil...................................................................................................................................
---•--•--•----•----••---•----••---••..........................•----•-•-------------............---•-----•---•--------------------.....--------•---------...................-•-•----•-------......_------
Nature of Repairs or Al1�ti — ... e1 dicabl ,_-------•------------•------------•------..... �------•-•---• .... ...........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispo§al System in accordance with
the provisions of TITLI, 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 of health.
Signed._.-_ ............�� /-
Application Approved By ............... --- - -- -........ ..................................................... -----1�
------------
Date
Application Disapproved for the following eason :--•---------•-------------------•-•------••----•---••------------------•----......-••-••--..........---•--.....
---•-•------•--...--•........................•-----------------------•--....---------------•-----------------••••---•---••-•----•-•--•••-••-•--•••-•-•-•-... •--•-•----... _...------• ---------------
Permit No...... - .............. Issued .............. .. ..�....a ............
Date
--.—__-------�yyTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... OF..... \. ,r:'�I�r ...........................................................
Trriifiratr of ToutpHattre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
bLnPL i 1'-------------•--•---••--------...._...-•-•-•--•------•-----•-•------------. ....................................
r' / Installer
at_ f% / ¢ Y� i ! 1.._..f 1. f._ e +f_:Vf fi �4 _J�'_'�._._..
__.. ..... ........... .__..._....- .._ . ._ •..
has been installed in accordance with the provisions of TJ.TLE 5 of The State Sanitary Code as/deseribed in the
application for Disposal Works Construction Permit No..M.--- 17?/ ................ dated. ------------- --------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THATTHE
SYSTEM WILL FUNCTION SATISFACTORY. 1 ;
I
DATIiy; / ----. Inspector -........ s --------