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App-Permit-Compliance
x MUbT CUNTACT HEALTH DEPT.DAY OF INSTALLATION. + '' No......80-58 4 Fus........ �.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------.....�a.w�---.---OF_......% a�l?�-1caf>.1.. ................................. Applirattion for Disvoii al Warks Tonstrnrtion 1hrmit Application is hereby made for a Permit to Construct (W.) or Repair ( ) an Individual Sewage Disposal --y tem at: '- ,v 57 1.v..I........-="-=l" la ..... G ........................................------•-•••................................................................................ Location - ddress or Lot No. �'. &44-02t/ 4d;KkA6&A1-1-a*V —761 ........ ... .Address a •............ Address -- Installer Type of Building Size Lot.. '6 529 �Sq. feet UDwelling — No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( ) Other — T e of Building No. of persons ............................ Showers — Cafeteria a Other fixtures ..................................... •--- W Design Flow ------------------------------- ------------gallons per person per day. Total daily flow .............. //©_._.._......._._.___gallons. fir' Septic Tank— Liquid' capacity /ocaa .gallons Length ................ Width..... ........ Diameter ---------------- Depth ................ J. Disposal Trench — No...KZ) ......... Width... Z............ Total Length .... !�P......... Total leaching area... 9!;�.......sq. ft. Seepage Pit No ..................... Diameter.................... Depth below inlet.................... Total leaching area ................... sq. ft. z Other Distribution box (SC) Dosing tank ( ) `-' Percolation Test Results Performed by .... !=H�...Fi41-4'fRF • Date..41 ---------. ,aa Test Pit No. l.:!<4 .... minutes per inch Depth of Test Pit ... %Z......... Depth to ground water ....... 7--.-_-----. w Test Pit No. 2................minutes per inch Depth of Test Pit.---...__.______.___ Depth to ground water........................ ---------------• ---�- o----�--•-t-------•--------------------------------------------------- -------------------------- Description of Soil_�� ............................................ =--,. t.J-�- .t �CGErUitf •-•-----------------------•-- ¢•.................. _---•.......EP......_A/A------•------------•----.......................................... -----•--------------•----------------------•----•----------------------•---•------------...-------• • --• •---------•-------• ---•-----•--•---------•--•-•---•-•-------•------•--•--•--------•-----•------•- Nature of Repairs or Alterations — Answer when applicable............................................................................................... ----------------------------•--------------•--•------------•---------------......---•-•--------------------•-•-. -------------------•-•-----------------------•-----•-----------•-------•---••-•-•------ Agreement : The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITL i:, 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.......... •------•---•-----•--------------------------------------••---------....---................................ Date Application Approved BY =-------------------------------------------- ------•---•------------------------------ '� " Da Application Disapproved for the following reasons-------------•--•-------------------------------------------•---•------------•---•-------------------------•----- ------------------• •--•- Date PermitNo --------------------------------------------------------- Issued -------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN .......................................... OF ............YARMOUTH......................................................................... Trr#ifirau of Tomplittnrr THIS IS TO CE19IF&What the Individual Sewage Disposal System constructed ( X) or Repaired ( ) t I at-----•-----------------•------------------- ------•-•----------.--------------------------------------------------••-------------•----•---------------•-•----------------•------------- has been installed in accordance with the provisions of TILT&B of The State Sanitary Code- scribed in the uu-japplication for Disposal Works Construction Permit No ......................................... dated .......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 1d111LL FU , TI SATISFACTORY. DATE ----------------k!1 1. •----............................................ Inspector ......... ................................................................