HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28
SO. YARMOUTH, MA 02664 /
No.-- . ........
Fps...%.�.N...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
dW.13. oF........
Awl•!1C.?.S.R1.........................................
Appliration for Disposal Workp Tonstrn.rtion 1rrutit
Application is hereby made for a. Permit to Construct or Repair ( an Individu 'wage Disposal
System at: 114
Locatio - Address or Lot No.
................................................................•-----------..... ..---- ...............................
��`- Owner Address
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---- ----------•••••••-------...........------............-----•---.-.--...-•--........_...._.......--•------.........
Installer -
Type of Building Address
YP g Size Lot.��t-13.Q1)•.... Sq. feet
Dwelling —No. of Bedrooms.......... A...........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .:"JEW . ................ No. of persons............................ Showers ( ) — Cafeteria ( ).
Other fixtures ..---•-••-• .......................... . •---......
Design ......................gallons per per d y. Total daily -fl-'O-
___..._........,./_�_ gallons.
Desi Flow----....... 1 t 1 �--�........... . .gall_ 4�
Septic Tank —Liquid* capacity-1.0Qv.gallons Length.f 3j..' Width.W .=10 iameter i•� •-Depth....JZ5! 4
Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No..Q-1.5.-.. Diameter .... l.Q�..... Depth below inlet ...... (2�1...... Total leaching area?_j12P`7j.)§q. ft.
Other Distribution box K . Dosintank ( )
Percolation Test Results Performed by ...... i�Q."i�c[�Sy,Date......
1��G?g....
Test Pit No. 1..e..Z.... minutes per inch epth of Test P,it..lg':G,? �1...Depth to ground water..4041r'_..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ........................
Description of Soil .... ?...--..4,6 ....... Kj
...7.22---
I.,— 1SnN
--------------------------------------------------------------------------------------------------•-•--•--......-------••••-•---•.....-•----....._....------................---.........
Nature of Repairs or Alterations — Answer when applicable................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal ;
the provisions of TITi.i, 5 of the State Sanitary Code — TPtpundersigned further agKees
operation until a Certificate of Compliance has beq;1X- e Ae`jearkpU=4.
Application Approved
Application Disapproved for the follo Ing rets:.........
................•-----•••-....--------•......--•---...••----...._...........-----.....-•-••.-----
Permit No ...... •--- S- -•----
to ccordance with
t to pl• e the sy�m in/
A j/rte
a.ti
Date
.----------•--•---..... •------------••.............. • ----•.....---
/e Date
Issued. L _ 0/ ----Y of . ....-----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH1Ve� C,,--;/Z�
..............:.5......... v... .. OF .......1.��%�. r'::'..r°ZZ<22.1-:.................................
Trrtifiratr laf Toutplianrr
THIS IS TO, CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by .................. '.._,:: :..................................
.................---............-•-•-------•---•--.........---.................. ...............................
.t .
,,���� %/� —Installer
at.................. _........:.._, ., ....._.: ir� .: z'_•--'^-------•...._.. �.. .0 d.. —.__......_... ' '._......'_'_._'._..................._...................._...__...
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 .....ti ........ dated --..--.i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CGONSTRUED AS A GUARANTE6�/THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY. �)
y
DATE.... l�� -- = f ......-_---• ..............•---•-----•-•---- Inspe" `{ ' !�`�.��: ..� ............................!zr�.
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