HomeMy WebLinkAboutApp-Permit-Compliancer. Q le i o(D
No.....1 0_--. Fims.... ........._...._......--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... Town---•-----•.OF.......Yarmouth....
.. .............•-••-•••-••-•-•-•-......-•...........••-
Appliration for Disposal Works Tonstrurtion 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
.._ 28 Swan Lake Roads West Yarmouth, Ma. 1—QT-;Sad{ ............ ------------
Doreen J.
Du8'Narmeress or Lot No.
W Cash's Trucking'nerInc . Address
............................ . ... .......................... .---•••-•-•---•--'••--------•-------•••'•---'..._..--•-••---------••-----•----•-._.._.............
Installer Address
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms ............ Z ...........................Expansion Attic ( ) Garbage Grinder ( )
P4 Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
P4
Other fixtures _________________________________ _
Design Flow ............................................ gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank —Liquid ca.pacity............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
3 Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---------------------•------._._....-----------------------•-----•----•-. Date ........................................
1-1 Test Pit No. I................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
x------------------------------------------------------------------------------------------------•------•-••----•--...._..-•--------••--•-----•--...-•------•-
0 Description of Soil....................................................................•--•---------.._..--•----•----------------•--•-----------........-------...........-------•-•---•---
"W
r,..........................................•--...----------------------•-----------•-----•--•-••-------•--.....--------------•------------------._.._..................__....•-•-•._....._.._......_....--
U
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Nature of Repairs or Alterations—Answer when applicable..._install__1,000 &allong_ holding_ tank,
three (3) diffusors, packed.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z- 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.
Signed.
--- -------- -------------------
igned
Approved By---othefoll
- -- --------•............. 1�� Z�--0
.�
Application Disapproved for ing r asons: ................................................................................................................
-----------------------•---'----••---------........-------'--•---•--•--------•--------------------------�----------•-•-•-•-----
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Permit No._(
o. O. --•---•------------------•••••--•- Issued .- IU -1
fix -- ate __ . Da -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�---
Yar, ,.ouch
..............Town ...............OF................................................................................
Trrtifiratr of Tn mptittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X)
by- .................................. -------------------------------------•-'--------------------------....._.._..._............-•----
28 Swan Lake Road (Doreen T. Du��t�r�e) `lost Ya �r�outliq iia.
at--•...........................•--------•••--.....--•--••---•-•-••--••---------•---•••--•- •-•-'-----••--. -•---'....--•--•....---......--•••--•-----------------
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 ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE
-SYSTEM PILL FUNCTION SATISFACTORY.
DATE......._ � -0.. Inspector�•:�:�: