HomeMy WebLinkAboutApp-Permit-ComplianceNo.... . ...................Ag,
1146 ROUTE 28
120
80. YARMOUTH, MA 02664 .
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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...................... .................... OF ....... . . ....................................
Appliration for Disposaf Works Tonstrurtion jhrmit
Application is hereby made for a Permit to Construct or Repair (� an Individual Sewage Disposal
System at:
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ocat n. Address
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Installer Address
Type of Building Size Lot ......................... ..Sq. feet
Dwelling —No. of Bedrooms............ 3 ........................ Expansion Attic Garbage Grinder
Other —Type of Building ............................ No. of persons...._.__.._..._......_...... Showers ( ) — Cafeteria
Otherfixtures ......................................................................................................................................................
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. I ................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....--........._._......
Descriptionof Soil ........................................................................................................................................................................
.........................................................................................................................................................................................................
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...................................................................................................................................... I ...... ........................................
Nature of Repairs or Alterations — Answer when applicable ... - ----- .... 4444-g,
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Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T LZ 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.
5' ne( i.-5 -- -------- .......................... --- ----
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Application Approved By .......................................... ! ............................................ ................................
Date
Application Disapproved for the following reasons: ................................................................................................. .........
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Permit No ......... 50-2--1 Issued.. --- .......... ---- Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
".............OF.............: * -k - -/ / ................................
Tafifirat. Of Toutplitturr
THIS IS TO CERTIFY, That _t)e Individual Sewage Disposal System constructed or Repaired (VI",
by-. ---- -- ...... ........ ........................................................................................................
Installer
at......... 14&.A ......... IA..I'e,_ S. .►.................................................
has been installed in actor ante with the provisions of TITL-1 ' '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 CONSTRUED A," GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--.. ................. Inspecton.." ---- ------- t ---- lw__r ......... ....
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