HomeMy WebLinkAboutApp-Permit-Compliancef<; Town Office Building
U2_+.. South. Yarmouth, MA 02,6.64
ny THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................................OF....................._................------------.........--.-•---
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Fns.. �Z.5 .......
Appliratiun for 14upuual i9orkii Tonstrudiun rrmit
( or Repair ( ) an Individual Sewage Disposal
Application is hereby , made for a Permit to Construct
System at
- Location - ddres
wner
.....1,►? ..........................................
Installer
.....................��
`............... ......
-- p�..7,�.�._....-.... or t v..._._. ..
Address
►�r�.................................
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 ( )
Otherfixtures--------•-------------------•----------.------•-----•-•-----.-----------------------••--------•- •.-....................................
Design Flow ......... ......................gallons per person �er�iay. Total daily flow... ...sem...................... gall �s.
Septic Tank — Liquid capacitQgallons Length_.e.-_.........._ Width . ............. Diameter................ Dept�hj. _���
Disposal Trench — No.......1---------- Width --Z .--.._ Total Length Total leaching area -
P g - g �-� ------
Seepage Pit No ..................... Diameter .................... Depth below inlet .................... Total leaching area .................. sq. ft.
Other Distribution box ( k< Dosing tank ( )
Percolation Test Results Performed Date. lz _ �....�
Test Pit No. 1--*:Z..-Z-_.minutes per inch Depth of Test Pit..,_.'2G2._._. Depth to ground water ......... aJ��__.
Test Pit No. 2................minutes per inch Depth of Test Pit ................ Depth to ground water ........................
-----.....--------------------------------------------............----.....---......------ ..-
Description of ---------
-•-•----------------------------•--•--•------------------•-----------------------------.......-------------•--------------•---.----
Nature of Repairs or Alterations — Answer when applicable ..........................
-------------------•--.......--•---••------------...-------•---...------.......----------------•------.........-------------•-------------------------------------------•--------------
Agreement:
------------ Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board of health.
Application Approved By...
Application Disapproved for the following reasons:
1--� - 2 y
Date
- - - --------------------------------------------.-------•---...---............•----------•----•---------•-------.....-------••-•--•.....--------
Permit No.... _.....................................- U z4- Issued------ I? 4 .Dau ----
Date
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................................... OF ....................................................................................
Trrtifirate of fanrntplutnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (� or Repaired
b ( )
Installer
at.. ..-=� .........1..---- i_'7-�'-==� - �'- .:..............................................................---------------------•--------••--------------
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 2.c'.:l_ _ ':`_--- ................... dated ._.. i f."?
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMA WILL FUNCTION SATISFACTORY. 7
_rl: __:.:. r
DATE----�'-'--?-- `---�'�---••-•---------•....................................... Inspector...::= ;::X' _ � '7 � � { l:'.r..........