HomeMy WebLinkAboutApp-Permit-ComplianceNo... ..... .-..27o Fxs.....fl .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................................O F...........................................
Appliration for Bisjmoal Works Toustrtt.rtiun 11ami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................_ 3 9- --• •-----.......... !................................. ......... .. ........ -- - p -g o.
Locatio_u-AddrKs or Lot No.
�) Owner
a................................ :::...................................................
Address
•-----•----------....-•---------........--•--------•--•-----•--------......_....----......--------
Installer
Type Building
Address
of
Size Lot ............................Sq. feet
Dwelling No. of Bedrooms ............................... .....Ex anion Attic � ng —-.-._--- p
( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................
Showers ( ) — Cafeteria ( )
Otherfixtures ..-----•----•------•-------------------------•-•---•--.....-•-------------....-•-•----------------..........---...-----•-•----......-----...----------
W Design Flow............................................gallons per person per day. Total daily
flow ............................................ gallons.
WSeptic Tank — Liquid capacity ............ gallons Length ................ Width ................ Diameter ................ Depth ................
x Disposal Trench — No ..................... Width .................... Total Length .....................
Total leaching area .................... sq. ft.
Seepage Pit No ................... . Diameter .................... Depth below inlet.................... Total leaching area .................. sq. ft.
Z 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 ........................
Description of Soil....
..................................... ------------------------------------------------------•-----•-------------- ......................................................
Nature of Repairs or Alterations — Answer when applicable ....... 1__`.- Q f�cu ......
-•-------------------•----...---•---------------•--•-----------•--------•---.....-----...------...----.....---------------------------------------------....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of AITL 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.
Application Approved By
--•----- ` -------------------•-•--•-------
Application Disapproved for the following reasons: ............
.... ...............................
Date
.......... ---.---
Date
---------•--•-•-•--------•------•-------•---------------------------------------------------------------- -•-•--........----........----------------------------•---3---------------........._------•---
Date
Permit No...... --- .-----------------•--------- Issued .................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH &'e-
:.: x....:�:'�OF......�1''..`....:..c::::...................................................
Tntifirair of Tuutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by--.........ram-'K.:............................•------••-----...............-------- ..-----------•------....------------------•--------- --..............--------•--....---------
- Installer
at------
has been installed in accordance'with the provisions of TITLR 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit __. ' �� �./ .. �
------------------ dated.....----="-----.....�--•-------...._.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. - . '�r1. ' /r Inspector_::. = �� �=�. '�" - • ......•--
.............. .c...... -'_....r...............__........................ ._._'- ,/'
f. -
No....IF Tovin FER
gouth Yarmouth, [VA. 02'.664
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HE LTH
'ir
.......... OF ..... .04
--yx .... . ....................................................
Appliration for Disposal Works Tonstrurtion lirrutit
Application is hereby made for a Permit to Construct or Repair (PoIr-an Individual Sewage Disposal
System at*
.. .........................................................
..................... ................
0 C.AIV, "d e* 6 / or Lot No.
...... ...... . .. . ... .. .. ............ A6, __
.. ..w...... .t.-----f......
..... .................... ...... .. t - - ---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. 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 .................................................................................................................................................
------ pli-i ...................................................................................
WV ------------------------------------------ r ----- ;F ---------------------------------
�Ra epajrs or Alterations — An _�>wer r wh a pli ... . ...
7
.. ... ....................................
Agreement:
The undersigned agrees to install the aforedescribed*ividual Sewage Disposal System in accordance with
the provisions of TIT 1 5 of the State Sanitary Code e tide ,ysigned furth agrees t to place the system in
oa
operation until a Certificate of Compliance has beep i5sdieZZhce oar le';ll
Signed...
Application Approved By
Application Disapproved for the following reasons:
Permit No..... $ .— 2- >,:D ... ..........................................
...... . ............................................
. .
Date
................................ ......... ss.
Date
.........................................................................................
..................................................... % ...................................
Date
Issued .... . ................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT9
......... ........... OF ........
Trrfif irate of Tontlifiattre
THFS 0 CERTUI�t du ,�kLewage Disposal System constructed or Repaired
Ale,
has been installed in accordaV w-ith the n provi * s of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction A/,rmit No ---- ? Y_::#2 2 ---------_-- ... ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector