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App-Permit-Compliance
s� P4 W 11 �W01 E E' tJ 01lCE' LiLlisG'sf3� No. ------• South. Yarmouth, 'MA. 0,2,66A FE$..1.�_....�........ ..o THE COMMONWEALT14 OF MASSACHUSETTS BOARD OF HEALTH ......... OF ..... ../ .....i4.71Q,�©....................... Appliratiun for Diuixuual Work.6 Tonstrartion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ('X) an Individual Sewage Disposal System at ...1_. �� ....................................... r. mo . �,{,�►,r© &/A( .. .--•--..--c son - dd e I ..--rhe: V N, -v fi r- A ©�� mac.. Ow r _ .......................................... Installer Type of Building Dwelling — No. 1611 alol /��-•---......----.......!/E. ,r p��� dd ess ,4 ...........................�/.!mow!.......................----............................ Address Size Lot ............................ Sq. feet of Bedrooms ....---.... �...........................Expansion Attic ( ) Garbage Grinder ( ) Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( ) Otherfixtures --•------•----------------•---...-•---•-----------....------------•--•--............. ............................. Design Flow_.__............................gallons per person per ay. Total dail flow ............... D ................ gallons. Septic Tank — Liquid' capacity.M? d..gallons ength--.... �_'...... Width .............. Diameter ................ Depth... ./ ftlle 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.__.. .. �!-�.L'�-`-L L yj ._ . Date.../water Test Pit No. 1.:'��=-minutes per inch Depth of Test Pit... ....... Depth to groun.......7------Y.-. Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ .............. Description of Soil ........... ......'` _./11 �------------------ .----------------------------------------------------•-.....------------------.....--------------------•-----------------............----•---...._.. Nature of Repairs or Altegations — Answer when applicable -�R.... �-'....?t...........�j'... U!V� .- �-l.Dad 00- --.. ---- �`�1i------..3... �-� L r------- v/6ic'r��+�Q!??sv..- W470 1 � ✓��c.l� AlB� t.... Agreement: The undersigned agrees to install the aforedes ibed Individual wage Disposal System in accordance with the provisions of TITUE 5 of the State Sanitary C e — The under si e urther agrees not to place the system in operation until a Certificate 453 nce hassued by he bo health. ..... .............. ........................................... �4f !P Application Approved By----••••--.......... •------------------------------ _------�--._.... Application Disapproved for ............'..............._.-'-............................._....._......_..._..............___............. (f� Permit No. ..C-..-`---`�------------------------ ----- -�--- Date....... Issued.--------- ._.._.. f ................. �D_ ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......................................... OF .... d.........:........................................................................ Tntifiratr of Toutpliatta THIS � TO CERTIFY, That.. the, Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................................�__ .....a r_ .....:_...----------- .------..... _.....-•----------•----------------------------------------........------...... y R Installe at............�.-f ......�"........................................ ���lr� E ----•- --- ---------------------------------------•--•••••--••-----•..._...---•--••-••••---....... has been installed in accordance with the provisions of TITI.EP 5 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 CONSTRUE.AS A GUARANTEE THAT THE SYSTEMA WILL FUNCTION SATISFACTORY. f y DATE ..... =..: :. .................................................. Inspector.—ii, nspector.-.X *� r