HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROUTE 28 FicE
THE COMM%&Vy&WQU3*iMM6SQRWSETTS
BOARD OF HEALTH
7-T.P�W7L ..................
Appliration for wiBposal Works Toustrurtion 1hrmit
Application is hereby made for a Permit to Construct
System at:
iiLo_,.;,on -Address
. . ......... --
-- ------------------------------------------
15;ne;
1&0 ...............................................................
Installer
Type of Building
Dwelling —No. of Bedrooms
) or Repair (44 an Individual Sewage Disposal
m_,a_
..........
................. -----
or Lot
WIq. . ..............
LV
Address
..........
Address V
Size Lot ............................ Sq. feet
--------- L ........ Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons...._..............._....__. 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. I ................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 ........................................................................................................................................................................
.............................................................................................................................. ...... ................................
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U Nature of Repairs or Alterations — Answer when applicable.-mxs4.0-d --- 10.0.0 ... --t . ..... 44>z ......
Q_� ----- F_6.%0AJ,4A*_e.M ...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Dispogal System in accordance with
the provisions of T I T iE 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 board of health.
7�;) ................................ .... 7.-A;s_-0(q .........
Signe L ..... .. 6 -
Dat
t
ApplicationApproved By ..... ... ......... .. ......... ........................................................... . ........ . ............
ate
Sign"
Ing
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Application Disapproved for the follo 'ng ryeons: ................................................................................................................
.......................................................................................................... ........................................................ ....................................
Permit No.... .---------------------------- Issued--__ / __Jage
......
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF...... (10- [01 Oct ...............................................
THIS IS TO CERTIFY,,,Tjiat the Individual Sewage Disposal System constructed or Repaired
by ........... ' _........<:.._._... •--- ......... ......... .....
......................... ...............................................................................
Installer
at................ / .. ............ 1.1�. ........ ... . ..........................................................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----------------------------------------- dated-------...-.----......------.--.---.------_.--.- �
THE
ated--------- --------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE -CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. X,
DATE. . ................
............. ...... . .... . ................................ Inspector-..