HomeMy WebLinkAboutApp-Permit-ComplianceJ
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Yarmouth, SAA. 0.2664 Flys•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i•." !
.................. OF ............. Y%�.. &v �=-------............. . --
, pphratiou for Disposal Works T, ustrurtinn 1hrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at.� / .. �.t. . ._ %- ............. --- - ..------- ----- � - .-------- M q P
Location • Address or Lot No.
...................... _......... _............................................................... -------------------•------..................-----.................................................
Owner Address
-----------------------------------------------------------------............................................... -..................................................................................
Installer Address
Type of Building Size Lot --.l ? Sq. feet
Dwelling—No. of Bedrooms ------ ................................Expansion Attic ( ) Garbage Grinder ( )
Other — Type of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
Othertures ---------------------------------•-----------------......--...---.......---------------.......------------------..............------------.......-----
Design Flow........... V ----------------------gallons per person per day. Total da' y�flow..-----............................._.......gal}ons.
Septic Tank — Li uid' ca acit tf7� -gallons Length __ Width.. -.7......._ Diameter ................ Depth -.4 ..........
P q P Y� ---- g � �-- - gg
Disposal Trench — No- -------------------- Width .................... Total Length ............ t....... Total leaching area.slj� � (, /0j
Seepage Pit No ------- /........... Diameter../,0_,Y-•---•• Depth below inlet... 59L ............ Total leaching area ........... .:....sq. ft.
Other Distribution box (Y,) Dosing tank ( / //
Percolation Test Results Performed by..Ze. �-_.. /,a 4- ��e_,Lr................ Date....... (��.....................
Test Pit No. 1. !! Z..minutes per inch Depth of Test Pit._lY ...-.. Depth to ground water .... I.VA T-IrIK11007
Test Pit No. 2................minutes per inch Depth of Test Pit .................... Depth to ground water ........................ E0
........................................................................... --•--•-•----------•-.........................................................
�Description of Soil--------------------------------------------------. —--------- �-- -----A&l............................................
---------------------------------......................................................................................................................................................................
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 be s e y the board of health.
Signed... --- -------------------------------•--- -------------------------- - ----
D e
Application Approved BY ....................................................... _._1?� Date
L ..� .---------•----
Date
Application Disapproved for the following reasons: ..............................................................................................................-
-••--------------------------------------------------•--...----...---...._..-----•-----------------------.------•------------------- --------------•---•--------------------........------------------•--
Date
Permit No.. ` -^------------------___ Issued.... I Z1 l a ( 4'
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR;D,OF HE--A-LTH
.......................................... OF .....................................................................................
�4
f�rr�i�ilctt�e ,af f�,anttttnr�
THIS IS TO CERTIFY, That the Individual Sewage Disposal S7st6h constructed ( ') or Repaired4( )
by...... t�. ELL .................
Installer
at------ .........---•---•-------------------•------------•---------------
------------...---------•------.....----•----•-----•----•---------------
has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._ 7_LP...................'.* dated-_- ......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
DATE._..._.: .. t. ' .__. Inspector ,'C' ,�,L�+'1!1�_.........-...:...