HomeMy WebLinkAboutApp-Permit-ComplianceTown Office Building
No. && Q Sobffi Yarmouth, N9A 025.64 Fizz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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Appliration for Disposal Works Tonstrnrtiun Frrnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( Z_)—a"n' Individual Sewage Disposal
System at
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.... �9 a �'�r..............................'� %_� ..................
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p Y / �} Ownf� �j
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alApir.-C .......... �!_._.` _1'q io Y /c K c-�" O JI .. ..............................
........... �.. .5_ � J ! � ld
dress
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Installer Address
Type of Building Size Lot ............................Sq. feet
Dwelling —No. of Bedrooms ......................................... ...Expansion Attic ( ) Garbage Grinder ( )
Other — T e of Buildin
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Other—Type g ____________________________ No. of persons ............................ Showers ( ) —Cafeteria ( )
0 Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow -------------------------------------------- gallons.
WSeptic Tank—Liquid capacity ............ gallons Length ................ Width ................ Diameter ............. _._ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter ...............•.... Depth below inlet.................... Total leaching area .................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-•••--•--••••••------•-------------------------•----------•---------_.... Date ........................................
Test Pit No. I................minutes per inch Depth of Test Pit -------------------- Depth to ground water.... ............
44 Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water .......... _.............
Ri.._.....----••---•----•---•---•---•----•-•-•-•---...-•-------•-•-•......................................................................
............
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O Description of Soil.................••-----•--•-•---•-•--•-----•-••-------.........-•---------•----------------------------------•-------..............----------..._...-.-----•--•--..._..
..-•-------•------------------------------•••-•-----•---. ---•-................................................................. ----- --------
Nature of epairs or Alterations — Answer wh ti applica.ble..___?'_.__...ld�___..._.___......................
f
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITi1j, 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
P p y the board of health.
e�
operation until a Certificate of Compliance
neds sued b -
✓�
Application Approved By •--• �'�'_�
1.__LAA...................... .. ............. K�?TSS
•-------
Date
Application Disapproved for the following reasons_ ____________________________ - ._..--..-...-.
p Date
Permit No.---..r:...b.-..... -- Issued �1
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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THIS IS TO CERTIFY, That the Individual Sewage Disposal Syst m constructel or Repaired (c��
by-•_. •---••- ....... _s-4?v� .......... J I', s �4 ......................
staller Y t' �C_ Q
at ��...U ........ ........ f � ��� ......... -_ - - - '� :. has been installed in accordance with the provisions of TITIZ 5 of The State Sanitary Coder as describgd in the
application for Disposal Works Construction Permit No .... (55-4.i.c) .............. dated ....... �.1�7.�_�.�...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,. -.
DATE < ---- Inspector. .tC` - ! �'=,'` --