HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28
SO. YARMOUTH, MA 02664
No. .'Ro'� ------ Fms... is" ....... ......
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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OF..---..�....-�� &`T...........................................................
Appliratiun for Disposal Works Tonuirnr#iun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
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Location - Address or Lot No.
----------- ---.- ............. ...........------------•-----------.............------....------------------....._........._...........
Owner Address
Installer Address
Type of Building Size Lot ... ......................... Sq. feet
Dwelling —No. of Bedrooms........ Y -------_--------------------Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Other fixtures .
Design Flow............................................gallons per person per day. Total daily flow ............................................ gallons.
Septic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter____-___-._._.-- Depth ................
Disposal Trench — No ..................... Width .................... 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. l................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
Description of Soil-------------------------------------------------------
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Nature of Repairs or Alterations — Answer when
.A rc.ow -C% i F is0LS1024 1W i 'A' S To U
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT%i: 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued by the board of health. q
Signed---------------•---------•--•- ---•... ••
ApplicationApproved By ........ .-------•---•...............•---------...---•--•--•-----------•--. •--------•-
Date
Application Disapproved for the f oll ing reasons---------------------•----------••--•----------------------------•----------------------••--••---.....---•-------
-------------------------------------ISSil--------. -------------------------------------Date--•--
Permit No. 32 ®d.------------•--------•--------------•- �{
ry THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................
Trdifirab of f ompliattre
by_.AHIIS ,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X)
5!:1.L_r`lA4(4J------------------------------------------------------------ ------------------•---- ..............---------------------••-----.....;....--•-----•--•----••--
Installer
at -i i'S'�—Tj,t'�td.t?
-•-----------------•-----....._._...--•--•--•--................-----•......--•-----•-•--•----•.
has been installed in accordance with the provisions of TIT T' �, of The State Sanitary Code es .1117 in the
application for Disposal Works Construction Permit Noda.tedt t __ ,��
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS Af �AR%ANTiE THAT THE
SYSTEM WILL / F�UyNCTIPN SATISFACTORY.
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