HomeMy WebLinkAboutApp-Permit-Compliance... �wnr. 1 rl NGr i .
.,.,..t 1146 ROUTE 28
- SO. YARMOUTH, MA 02664 Fss........•• _
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F..........._.................._.......--.------------....._..
Appliration for Dispooal Marks Toostrurtion 11truttt
Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal
System at
.......................... - . ...... 1---- -----------------------------------------
Location •Address (h "T3r or Lot No.
....... �M. ....� .2. � �_ .'. .....1 .4 -------------------- ••---...---- `� -• .. [..�. ! 1!� 1� a - - -...............-•--
Owner
,Wj -�� - 3• -r = S ._ ..... ? i -.....�--Sgskh---------------------- ----- A re s
,
Installer Address .
Type of Building Size Lot ............................ Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther —Type of Building C°c Lv?.-, r,3.1........ No. of persons ............................ Showers ( ) — Cafeteria ( )
dOther fixtures ....... ? .- �^"' si-ate l i �1-----•.......................................•--------...........------.
W Design Flow 5 p! -t P� �.PA.1A0At= ..gallons per person per day. Total daily flow ........... . ................... gallons. l
WSeptic Tank — Liquid ca.pacityl•'1d2O..gallons Length-. Z0--_........ Width.. ---------- Diameter ................ Depth -...—V .*
x Disposal Trench — No ..................... Width .................... Total Length_--_------.-_----- Total leaching area .................... sq. ft.
Seepage Pit No ..................... Diameter.--/ _ o'�.. Depth below inlet--- _-4'0..*'--... Total leaching area .................. sq. ft.
Z Other Distribution box ( J) Dosing tank ( )
aPercolation Test Results Performed ........... Date Date......._�:_..f .__✓�' ......
Test Pit No. 1 ------- ....... minutes per inch Depth of Test Pit .... Ile. _"..... Depth to ground water .... 9. -;6 ...........
fr Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................
P4---•-•-••-------•----•••-•----------•-----•-----•-------------•-------------••...........••-----•---•------•--•------------------•----•-••---•---_--•-•-•--.
D Description of Soil .......... � ns►1_ kr - ° .t �4ue--•---------------•-----------...------------ ...........................................
W
v•--- ----- ----- •----•---------------
w
UNature of Repairs or Alterations — Answer when applicable............................•.•._._...--....••......._....._............._._............._.....
-----------------------------------------------------------------•------......---••-........---------•-• •------•---• ••---• ••----•-- •-••---•-----•--------•------.....-•---.--•--•-------•--------•--•---
Agreement : Zt
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 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
byy the board of health.
Sign G ���----_--_--•-•__...- -_---�•-/�--
Application Approved By .............. ....
-------------------------------------------------------
Date
Application Disapproved for the folio ng re ons:•-•---•-•----------•------------••-------•-•------•----•---•------•.......--••-•----••-•---•----•-•-•---.....--
.........-•-•.........................•-----•------•-----•----------•-•---------•-•----•...•-•---•-----..._..._......._....--•••------•-••---••--------•---- •-••••••---•------•-•---•----------
Permit No....Z....................................... Issued. - 7/
-�--• . Date
......
Date
THE COMMONWEALTH OF MASSACHUSETTS
�t
BOARD OF HEALTH
. loci.
......;.... :'Lr .lt:..............OF........;....f�:.........t�l................................................
(Irrtgfirab of Tumpfinure
TH IS TO CERTIFY, That the Individual Sewage Disposal System constructed (��` of Repaired ( )
by .... rT ! ......� . =-----.. c1 ! 5 ------ ................ .... ...------•.
J f,7 Instal}fey, ��� _ j��
at m' - .!C:�r �� _ ssst 'J - 1� 1(/t y = Uyz«t _�_ -"=• / if .. .
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 .... ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS,A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �'
DATE ........... ,1e.. Y %/ ��' .1.
Inspector.. ?� - - • -
_ r