HomeMy WebLinkAboutApp-Permit-ComplianceFEB .O �R
THE COMMONWEALTH OF MASSACHUSETTS
' ROGER e�GV
BOARD OF HEALTH
q PAUL
�Sp� MICHNIEBNICZ
TOWN YARMOUTH rj No.30420
OF..................................... ............ ......................................... CIVIL p
Aptiraation for Ui-4pnsal Works (gowitrurtion Frrutil�
Application is hereby made for a Permit to Construct 6xX) or Repair ( ) an Individual Sewage Disposal 4 29.
��S,,yst/em at
?"C:..L.l.p RUS SO.._..... ROAD--• .. - - .LOT.«®. ` i::1......._....«�:�:�......................
---------•-
Location < Address or Lot No.
'l ^
•--•^"""""-" Address
/. Owner
Installer Address 6 7 6 3
Type of Building Size Lot____________________________ Sq. feet
D;velling —No. of Bedrooms ................ 2 ...... Expansion Attic ( ) Garbage Grinder (ng
Other —Type of Building ---------------------------- No. of persons ....... __-_--------..___-- Showers-{ -) — Cafeteria ( )
OtherAxtures--------------•-------- ----- .....-----•-•-•------.._..--- --- . -4.. .
Design Flow -------------- 55---_--- __---------__-_gallons per person per day. Total dailyflow_ 2 2 0 ,; lons � ..
Septic Tank — Liquid' capacrtY...1. pNgallons Length_g!_...6.!!- Width _. Diameter ...... Depth_ ----
q.
p ' g ...... Total leachi g area --- ------ ----sq. ft
Disposal Trench — No- ------------------ -
p
Seepage Pit No ........ Diameter:_...._._....._.... De th below inlet_..... .... 194 t t
Width_____________ __ Total Length Tota eac m urea__ s
Other. Distribution box (X Dosing tank ( )
Percolation Test Results Performed by___________________________________ 10.-.0-'.._ Date 8-1
Test Pit No. 1 ................ minutes per inch Depth of Test Pit 11 0'' � Depth to ground water none
Test Pit wNo. 2.-_ 2......-_nii utes er inch Depth of Test Pit __:-...'______._.. Depth 0' roup d ate -----------
Test OpO-0' Humus 1.0'-2 0' subsoil, 0 % 0 med coarse
--- -
.
_i"n "'n (I rnan a_A 11ratr�r� RAn TP 2 00-1 . 0' r1umLT's
-----------S- 6-------------••------ ------
coarse sand.
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Nature of Repairs or Alterations - Answer when applicable. ...........................
............ f,g.............................................................................._._...._____....
Agreement
The f.L.Indersigned agrees to 1
the provisions of TITIE 5 of the
operation until a Certificate of Col
Application Approved By__K
Application Disapproved for the
the aforedescribed Individual Sewage Disposal System in accord,
Sanitary Code= The undersigned further agrees not to place the
�e has been issued by the board of } ealth.
Permit No..�--& --`7---�---------------------------------
Date
THE COMMONWEALTH OF;:MASSACHUSETTS
t *'
BOARD OF HEALTH
J r�
.........................
.. .........
OF.
......................................................................
��erti�irtt#r u$ f�lant�$i�anrr
THIS IS TO CERTIFY, That the Individual Sewage Dlsposal System constructed ( ) or Repaired ( )
Installer
at. �-.... -----------------------------•--•. ----------•-----•--------------•-•--••--------•-•-•--•----•-----•------•----------.....---------------
has been installed in accordance with the provisions of TI df; ;5 pf The State Sanitary Code as described in the
application for Disposal Works Construction Permit No...------------------- ............ ------- dated .... ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ................................................................................ Inspector.. _
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Date