HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH DEPT. z
Na•�_. �13� 1146 ROUTE 28 A"
S0. YARMOUTH, MA 02664 Faa..........5 ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........._.... _................ OF .. ................................ ....................................................
Appliratiou for Bho-Votiul Works Tonstrurtiou Vamit
Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal
S stem at: 1/
49� �.
ation •Address � � / or Lot
....................................................
Address
a.1. 'Kf.. CSS?l )t.--... "ar.✓ �f^.-t�slt.4.:11..-•-��---'.................... )& ........... - ,,,• '', "..............................
p� Installer Address
6 Type of Building Size Lot.../..,5/`:r2t?.V........ Sq. feet
H Dwelling—No. of Bedrooms........................................Expansion Attic ( ) Garbage Grinder ( )
WOther — Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P4 Other fixtures ............................
W Design Flow........../../..Q.........................gallons per person per day. Total daily flow... ........... -..--.... gallons.
WSeptic Tank—Liquid capacity4,20.Q.gallons Length ................ Width. .............. . Diameter................ Depth-...............
�+ 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 ( )
aPercolation Test Results Performed by.........�.�l�E�e�....................................... Date........................................
1 Test Pit No. 1 ..... ..-.....minutes per inch Depth of Test/Pit.................... Depth to ground water........................
W Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
N---........................................................................• ...............................................................................
0 Description of Soil ................................................. ...................:.....•--•----........ ............................. ............................................
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txj Nature of Repairs or Alterations — Answer when applicable................................................................
Agreement:
The undersigned agrees to install the aforedescribed Tndividual Sewage Disposal System in accordance with
the provisions of TITLY
operation until a Certifi
Application Approved
Application Disapprove
Permit No..... a—
L733 C
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
t.oF.... .........a....Z................................................
(gertifirate of ftiomptiatto
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( - )`or Repaired ( )
-n Installer
,
at....--..' = -'. r ...... `C..................•c.:.... s :