HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28
No, q_y SO. YARMOUTH, MA 02664
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAtrTH
.-- .............................-----.....OF.. .......•----.......
,!b.%2.%t!"�t^...............--
Appliration for Di-sposal Works Tonsirn.rtion jrrmit
or Repair (L,4an Individual Sewage Disposal
Application is hereby made for a Permit to Construct
System at
............ - � -- v- j`•�= V`5-....�.................•---......
Location - Addr s
..........
------ .__ .......................................................
Installer
Type of Building
Dwelling — No
Other — Type
Other
. of Bedrooms.
...........................................................................
�
,/A� WI _ _/ Address
..............f - .....................-•-•--^--•---..•..........................
Address
Size Lot ---------------------------- Sq. feet
.....Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons ............................ Showers ( ) — Cafeteria ( )
fixtures-----------------------•--------------•-•---•--------.--••-------------•......
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 ........................
----------------------------------•-----.......------------.....--------.............._..---------•- ------.......------•--•------.......---•--------•------•-
Descriptionof Soil ........................................................................................................................................................................
............ ----------- --- ----------- - -•- ---- . --------------- . -- ----------- - ------•-
Nature of Repairs or Alterations — Answer when applicableL��......_.�..''..- ...... y..w�Y"J
.--------...-•••--••- ...
-------------------------------------------------------------------------- -............................................. .............................................................
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. /
Si ned.::ti-.... �-' '-------------------------------------- Yl `
Da �
----------------•---•----••--..............---.-----
Application Approved BY ....__...
Date
Application Disapproved for the following re ns: ...............................................................................................................
-----------------------------------------------------------------------------------------------------------------------------------------------••.....................................
U L
Permit No.... ..� i g.l-------------•-----------. Issued --------------� -- ....... �------....
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;.........: ....... OF.... ' ......................................................�f
Trriifiratr of TOutplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ----------------------i2 =='............... .: r-'.......................................................
...:...........-----•---------------•- ----------------------•---------------•---•------.---.-------- •---- ---
/ Installer
� r
at .......... .....t 1.:....------------------•---------------------------------------------------------------. •-----.....---•--•--------.....
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 ......................................... dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE,THAT THE
SYSTEM WILL FUNCTION. SATISFACTORY.
DATE ---
S
.................................................. -•--•-•. •---......... ----. Inspector .4t-_12,
:,..'.r.� ,� -- _r`. ---------
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