App-Permit-Compliance1146 ROUTE 28
SO. YARMOUTH, MA 02£64
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... .................... OF......................................
FEZ /.f
Appliration for Disposal Works Tonstrurtion Frrnti#
e.
Application is hereby made for a Permit to Construct ( ) or Repair ( an Indiyidual Sewage Disposal
System at •
Location - Address
Owner
Installer -------
Type of Building
Dwelling —No. of Bedrooms ...........
Other — Type of Building ......._..
Other fixtures ............... X
N
Design Flow ....................................... g Ions pe pe
Septic Tank — Liquid ca.pacity....... _..-g Ions L ;
Disposal Trench — No .................... W dth ..........
Seepage Pit No ...................... Dia ete .................... E
Other Distribution box ( ) Dosing tank
Percolation Test Results P rmed by ..............
Ll�1�_ - ��° 1 1...- .1L7 .-
/No
x�j , A /� Address
............. ........... ..........�......-----------•-•----.............................
Address
Size Lot ............................ Sq. feet
....Expansion Attic ( ) Garbage Grinder ( )
persons ............................ Showers ( ) — Cafeteria ( )
............... ---------------•---------------------------......................-------------•-•----•----
)n per day. Total daily flow............................................gallons.
l ................ Width ................ Diameter---------------- Depth ................
Total Length .................... Total leaching area .................... sq. ft.
th below inlet .................... Total leaching area .................. sq. ft.
---- 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 ........................................................................................................................................................................
----------- --• c
-----------
-...-----•---
Nature of Repairs or Alterations —Answer when applicable.__ :.._x_ ______________... �_._�_l.__..._..___..........._..._......._.___._._....._..
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.
Signe / --- -•--- Jr _.—...................................�i/ _/
Application Approved By--•- ! -- --- - -- ----- -------- ---- - ..... ,..................
Date
Application Disapproved for the following reasons:
--------------------------------------------------------------------------------------------------------• -------------------------------------------------------------......---------------------.....--
PermitNo.-- f --.L '46 .................... Issued-/-Ydr......
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Z5'111�1�`"t I ................... OF ........... .r .yz� ...e,, I ,..
(rrtifiro#r of Toniplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�.}
y1.L�...... '' -------------- =--------------------------------------------------------------------------- ---
j i Installer
--------- ----------------•-----•-----.-------•-•---------------••-------------------------.---••--------
has been installed in accordance with the provisions of TITLI 5 of The State Sanitary Code as described in, the
application.for Disposal Works Construction Permit No._11.'_ :_ �'� '_�.._..__... da.ted__.._F�':..Z.:..aZ.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY ,--/—�
DATE ......
- .. Inspector .