HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT.
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THE COIv� &*1R 0&TB.F'M&§U6*USETTS
BOARD OF HEALTH
oWn..................OF.... Csr..vno.c. i.�...... ...
. ppliration for Disposal Works Tonstrortion Permit
Application is hereby made for a Permit to Construct ( ) or Repair (�-) an Individual Sewage Disposal
System at:
...----- �Q7`-- 1999 .1'?2P-3..............
Lot -
.•�Location -Address or Lot No
..........
Owner Address V
Instalier Address
Type of Building Size Lot ............................ Sq. feet
aDwelling —No. of Bedrooms ............................. ..........Expansion Attic ( ) Garbage Grinder ( )
aOther — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
d Other fixtures ------••----•-----------
W Design Flow............................................gallons per person per day. Total daily flow ......................................
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .................... Total leaching area.
................... ft.
Seepage Pit No ..................... Diameter..........--........ Depth below inlet.................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tank ( )
a . Percolation Test Results Performed by .......................................................................... Date ........................................
M ' Test Pit No. l ...............minutes per inch Depth of Test Pit.--................. Depth to ground water.....................--.
fA Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water.--.....................
�a----•--------••---------•...•-••••---------------------•........
Description of Soil .....----•-••---------•--•---------------------•-----------•-•-------•-•-•----------------------------------.....-----•------.........-•--------•--•-•-----.............
W
W--•----•-------------•--••-•••----...........................--•---•-•-------•.........--------------•----------•-•---•--•-•---•-------•-•---......•----...••--•-----•-----•--•-•---•-•-....•--.......--
x...........................•--•----------•--•--••-----......-----•-••---------------•••---•-•-•--------••-••---------------•----•-••-----••----•--...-----•-• -..... ------ . .......................
U Nature of Repairs or Alterations — At}swer when applicable. ?to aAQ....lood _zsS .t- /..Zn Soft-.-_•,
... W..--4n;t4_Q6_..t-Lur.*4 .........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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.
igned- --
- ---- '
------------------------------- ---- -- ......8
Application Approved By ................ -----------------------------------------------------------
------- 4.1.1i) ---•-----------
ate
Application Disapproved for the following reasons:--------•---------------------••----•--------------....----•--------------------•-------•---•--••......-••......
Date
Permit No....---- ..y.. -----••--••------ Issued- ......... _ �!� r .................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... G.l!? r ................... OF....... ��c.t c1:iQ .� t:4F....................................................
Trrtifirai of Tompliaurr
�. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
.......... z ............ r................................................................_------...........----........
Installer
-' ................................ ---...-••....-----------
�t ' .. -----•--•-•-----•-• .............•--•--•------
has been installed in accordance with the provisions of TITIN 5 of The State Sanitary Code,/as described in the
application for Disposal Works Construction Permit No.... .....;t' - 1 �......... dated.....ja _� �....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE............................................
Inspector.,,,,< .. _ ; .�.......... .:..