App-Permit-Compliance / 294N .� ....... .Fins.......� C_. _� ....._
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
.._ ................... OF ......... .......Xar.mg th.._...........................................
Applirtttion for Uioposttl Works Tonotrnrtiott Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Fruean Ave Lot 10&11
Brewer ReaPV§O1TV69't 100 Old Town 4`169&9b Road S.Yarmouth,Ma.
.............. ................................................ .......... .......................................................................................
Qwner
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Installer Cc 6w S(w �?�a: Address
Type of Building I Size Lot.. .......................... Sq. feet
Dwelling— No. of Bedrooms ................ 9t........................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building ...
..steel No. of persons ............................ Showers ( ) — Cafeteria
9Lavatories( )
Otherfixtures......---------.-......................................................._.................................... ........-
Design Flow............................................gallons per person per day. Total daily flow .................... ........................ gallons.
Septic Tank —Liquid capacity ............ gallons Length ................ Width................ Diameter................ Depth ................
Disposal Trench — No ..................... Width.................... Total Length.................... Total leaching area .................... sq. ft.
Seepage Pit No_ .................. Diameter.................... Depth below inlet.................... Total leaching area .................. sq. ft,
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by ................................... ....................................... 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........................
Description of
Nature of Repairs or Alterations — Answer when applicable ...............
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.
`/'^Q'-'��
CL.� Signed.. .... -- --.-; __ .....�.t^a—!-ram.. Y.,...-/.i=..-v� .--- -- .
Application Approved By-------C iv
D
------------- - .. ...---......-....... • !/ r
ate
Application Disapproved for the following reasons:... ........ .................... .......... _.................. ................................................
//' Date
Permit No ......... _ .,l.... -------• Issued.-------4 - •• �� J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
::........................ OF .... .................................................
(9rdifirate of Tomplittnre
TO CERTIFY, That the Individual Sewage Disposal System constructed (`>-,) or Repaired
has been installed in accordance with the provisions of T,)TL: 5 of The State Sanitary,,CPdefas described in the
application for Disposal Works Construction Permit € IQo ( :.._•'s.................... dated.rA f? f ..............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEMWILL FUNCTION SATISFACTORY. )
xa i , . a/
DATE..,41. _.. _=.............................................. Inspector,,...w
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