HomeMy WebLinkAboutApp-Permit-ComplianceNo .. --4-383...... FEa 15.00 ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH f
TOWN YARMOUTH
......................O F.............................-....--......-.......-...-.---.........--------•.-.........--
Applirtttion for Bisposal Works Tonstrudion 1rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (K ) an Individual Sewage Disposal
System at:
9 CIRCUIT RD., N., W.Y.
PHIL WHITTEN Location -Address or Lot No.
Owner
Address
W-----•---- ..... • ....
.............•... .._..._...
Installer
Type Building
Address
Size Lot Sq. feet
of
............................
U Dwelling —No. of Bedrooms______________________________ _ _ .Expansion Attic (
) Garbage Grinder ( )
Other — Type of Building ____________________________ No. of persons ............................ Showers ( ) — Cafeteria ( )
P4Other fixtures ...............................................
W Design Flow -------------------------------------------- gallons per person per day. Total daily
Length Width
flow. ........................................... gallons.
Diameter Depth
WSeptic Tank — Liquid capacity ............ gallons ---------------- ................
............... ................
x Disposal Trench — No . .................... Width .................... Total Length .....................
Total leaching area .................... sq. ft.
3 , Seepage Pit No_____________________ Diameter .................... Depth below inlet ....................
Total leaching area ................. sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by .......................................................................... Date ........................................
,1.41 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 ........................
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ODescription of Soil ........................................................................................................................................................................
x
V -• -------------------------------------------------- •--•-------------- •------------------------------------------ _______--------------------------------------------
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- -- ---F R
U Nature of Repairs or Alterations — Answer when applicable.-_ 10008 TANK - 3 FLO DIFFUSERS
.......................... --------------------------------•-------------rix ..............................................................................................................................
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
S ned r-----�/eS �......
Application Approved By =- /....----------------- ---- ----
Date
Application Disapproved for the f ollowin( reasons:
Permit No ........
.y.-.....s�3...................
--------------------.....................................................
..........................:...............................................
Date
Issued_ --------- E_/_`_E.Y....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... GOWN YARM.0R.'II
.......................... O F.....................-................-.-........................................_...
�rrtifutt�tle laf f�um�rlittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired X )
by :��..... Vic. --------
-- .H •----------•.......................................•---...------
S CIR.(_'UIT RD., N, W.Y. Installer
at........ •-•---•-------------•---•---••------•••--•-----------•--•---------------------•-••---•-----------•--------------•-•------------••-------•-----------........_._._.....------••-•-------•---
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 ... 84:=383________________________ dated --71-2684
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
t•------•-•---•-•..............•---•---••---------------••----•-- Inspector_..r�