HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH TN DEQ'
No.J 1146 ROUTE 28 Ficip��
THE Ct710(MO"NWALTH' MA F MA2664
SSACHUSETTS
BOARD OF HEALTH
------....I ............ ..................O F.
Appliration for Di-opmal Works C onstrurtion jhrmit
Application is hereby made for a Permit to Construct
System at
L LJ } Location - Address
�„p Owner
Installer
Type of Building
Dwelling — No. of Bedroo
Other — Type of Building
Other fixtures
) or Repair ( ) an Individual Sewage Disposal
.............. . aT- ria 4- vn 4-P - ---------•
- - - .....................
'p , .. or Lot No.
- V �---------- ----------•-----------------------------•---------
Address
.._.... ---------------------------•---•........._..-•-
Address
Size Lot ............................ Sq. feet
.................Expansion Attic ( ) Garbage Grinder ( )
No. of persons ............................ Showers ( ) — Cafeteria ( )
-------------------.•--•---•---.....---------•--------------........--•---•...................................................
Flow...................................... .. .ga s per person per day. Total daily flow ----...._.._....._._...._..._...............gallons.
Septic Tank — Liquid capacity------ ' allons Length ................ Width ................ Diameter--.............. Depth ................
Disposal Trench — No ................... . idth.......... ........ Total Length .................... Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diam ter- ---.-.--.......... epth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( ) Dosing tan ( )
Percolation Test Results Perfo d by.......................................................................... Date ........................................
Test Pit No. 1................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 ..........................................................
..............................................................................................................................................................................
--------- ----------- --
Nature of R:e� or. Alterati —Answer when applicable - -.- puJ ...................`J-.. ..r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi: 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 y thl~ board of health. Com/
Signed..- --- t ` c --
ApplicationApproved By ......... • . •. •-•-•-• ••----......................................................... .......
Date
Application Disapproved for the f ollowi re ons: ................................................................................................................
..---------------------•---------•-.•..--..........-f-••-------•.......••----....-------•.-•-----------------------•------•-•------- -------------- --...........
:.
Permit No.-•_.--•-------------------------------------- Issued ......... 5 �� .
....Date
��.......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
.......ill.A'ZI............. OF..... 1.......6/6 1�T1.....................................
Trrtifiratr of T ampliaurr
THIS,4S TQ _CERTIFY, T at the Individual Sewage Disposal System constructed ( ) or Repaired `
b...... .....n.....---
�,
at....... /IL.GI --••-- ' !J----•-. - .
has been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code as described in the
application.for Disposal Works Construction Permit No ------ ......... dated--... :-:.1._--._.-__.-•--_-.-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... ::........ ......� �" % _.
...................•--.....------•------------- Inspector... -----------•----.rf��� .------ -�-_= -_`_- -..................