App-Permit-Compliance / 293No. ----......`.....1
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THE COMMONWEALTH OF MASSACHUSETTS
— BOARD OF HEALTH
lot-V-). ._ .................OF..... Yarmouth
...........................................................
Appliration for Mripwgal Works Tianotrnrtion Fermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Fruean Ave Lot 10&11
................ -__.._...........................---...._................................•...--•-----------•----•---------.................................................................
Brewer RealLtfi0.Tk`t6st 100 OLd Town4ffeazbe Road
_..._..........._.._ ................... ............. .......... .... _................................. .................................................
w Cyr_ `�..a u _EmHtn. Great Weatern Rldgds, Dennis,Ma.
. a ........................................... .............................................................................................................................
p� Installer Address C'o U Type of Building C C .v C,`fn It ra n .
Size Lot ............................5 feet
Dwelling —No. of Bedrooms.. ........ 0...............................Expansion Attic ( ) Garbage Grinder ( )
WOther —Type of Building ....... steel- ..... . No. of persons ............... _........... Showers ( ) — Cafeteria ( )
Other fixtures ...... z.._lavatoYles.......... .....
................................. ................
.....
W Design Flow .................................... ........ gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank —Liquid capacity ............ gallons Length ................ Width ................ Diameter................ Depth................
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 ( )
a
Percolation Test Results Performed by ..............'-----....•••--------------'-.....---............ Date ........... ......---..................
M Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
k, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4----------------.......... ------............................................. __................. ......
..............._•.
0 Description of Soil ................................. ............---------.........••........................... ........................................................... __........
W
--------------------------------------------- -........... -------------------- ----...... •----•----------------- ..........-------------------- .......---------- ....•------------------............
w
UNature 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 TITIS. 5 of the State Sanitary Code — The undersigned furd:er agrees not to place the system in
operation until a Certificate of Compliance has been issued b the board of health.
Z' t `_ 6 'Signed ...............' -- ------'-------- .. S ;�-Sb .
Application Approved By.....-�`.:1... -'�� - - 1 �lC) =
............ .
• xe
.tion Disapproved for the following reasons:------..........................................................................................-......-----
y--------/✓----------------------------------•..-----------------------------------......................
" ......l.t.._ l/ Date
// C� -----
Permit No ................ - Issued ..... Cf ......•.•..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
yf>! . ....................... OF... t.I. G..'.t(-.Sl:....:'t..................................
...........
.......
................
(9rdifirate of Tomplianre
IS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Insfytalter
.........................t a ti. .tsi .: tr {FT i ................................................. _______________
has been installed in accordance with the provisions of T-ITLE j of The State Sanitary Codefas described in the
application for Disposal Works Construction Permit No.: :._.. `.?..,.>......._........... dated-(:`.........i.............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. it
DATE_,, t r ......:.. :.:f ` ( .............................. Inspector... ------
- -' s............................................, .