HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
1146 ROU1'E 28
No. -- -•• ..................Fins_-.-.
_
SO. YARMOUTH, MA 02664............. -..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... ..................... O F..........................._....................
ApPration for Dispoul Works Tonstrnr#iun rrrnat
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individ& Sewage Disposal
System at • t°j. b 1<353
-•L do V - A dress or Lot No.
v�...._. .. - • ........................•----•----^•-----..--.................---
4 Owner (^ Address r�
Installer
Address
Type of Building Size Lot.........................Sq. feet
Dwelling —No. of Bedrooms__- 3...............................Expansion Attic ( ) Garbage Grinder ( )
�Other — T e of Building g ............................ No. of persons ...... ...................... Showers ( ) —Cafeteria ( )
Other fixture ........................
...........................
sDesign Flow..-----..---�...........gallons per person per day. Total daily flow ...........
.�..................... gallons.
14 Septic Tank — Liquid capacity ............ gallons �ength................ Width.............. Diameter ------ .......... Depth ................
Disposal Trench — No..-/--------------- Width_,9 ............. 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. 1................minutes per Inch Depth of Test Pit-----..-_--------_-- Depth to ground water ........................
Z Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
-----------•------------------------•----------.....------------•-----....----------------•-•---••--.........................................................
Descriptionof Soil ........................................................................................................................................................................
..••-•-•--••-•----------•-••--•--•••--`......•-•------•-----•-•---•------•------•------•---•--••-------•--------•-••-•----------•-------•--•-•-------�-•--• .
Nature of Repairs or Alterations — Answer when applicable.---------..��i� ....... :Q? ... ,p
�R'"--------•-_ �
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITA U, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Complian b the boar o -
S' ned......... .... . t
t
Application Approved BY .............................................. -••--_.... i .,�.._........
ate
Application Disapproved for the llowi g reasons: ---...-----•--•--•--•-- ..................
No ..... -0 `'' - 3 3 ...--------
---------•--•--•-----------------------------------------------•--••---•--.
Date
Issued --------... .........
/ Bate
{' THE. COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c-
(9rdifiratle laf Toutplittnrr
THIS 1& T -O RTI : Y, That Ae•-4n(1 Sewa Disposal System constructed orr Repaired �-}•-'"
% Installer
at.. ----
has
- has been installed in accordance with the provisions of TITLE j 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 AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. � ---
DATE ...... a.../ yr. 2 .......................... Inspector ..... / �' a = - '..............................