HomeMy WebLinkAboutApp-Permit-ComplianceYARMvu In r",......
116 ROUTE 28
Ido. ..._. .. SOYARMOUTH, MA 02664 Fss .sf/..._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... . S ..-.....- - ----
Appliratiun for Disposal Works Ton,stru.rtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair (i,�an Individual Sewage Disposal
System at:
........ 3 !E- L Aloe ��-- - W�2,S % U7- E (� S
.__........................• .._. .---------- - ... .....--------------- - ........ ........................
�— pLocatign - Ad ess J �/� or Lot No. q ,
.....:....✓._«.L.............lr./.._JOrbher........................................... l/i% �.�1:._..`�jC�L(�1f�1T!.Y................... .......
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.....................................
Installer Address
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................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. 1-•••--•••-. ..... rninutes 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 ........................
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Descriptionof Soil ........................................................................................................................................................................
............ ............. •-• ---............ ------ ---------•----- . -- .
Nature of Repairs or Alterations — Answer when a licable.-� b. % b �C________________
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Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 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. % G'
gned- .�/►/ ' r./t------•------------------------•--•--•--------•-- / �•b
Application Approved By----. a
Date
Application Disapproved for the following reasons:-----•--------------•-•------------------------------------•--•-•-----------•--------------•------•-----•....._
Permit No...D .`..:</--------------------------------
----------------------
- --------------------------------------------
Issued ._I ---•---•---------.Date --•---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OHEALTH
j0/
U, �.� �.................. OF ........... loll%.... /.. e.............................................
(9rdifirair of f omplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by......,. .......... ✓-Q- .............. -- Installer --•--•----------------•------ ....._.. ._...----------
atQA__............ �.. �.- --------------------------------------------------------------- -........................... .--------------
has been installed in accordance with the provisions of TIT/LLE 5 of The State Sanitary Codas scribed in the
application for Disposal Works Construction Permit No....d:F�
/--/ --------------------- dated.-.-�.s.�.�..................•-.-...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------------------------------•-----......----•--•----------..---• Inspector