HomeMy WebLinkAboutApp-Permit-ComplianceNo .... 8.2..211....... FiLA5..0.0.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-. .............O F..--.......................---....... -.... ......... --..............................
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Apptiratiuu for Biuvuuttl 10orkii Tumuurtiuii Vamit
Application is hereby made for a Permit to Construct
System at� �
ocatiou - ddress
= = -)--•------------------•--------------------------
O er
Installer
) or Repair (X ) an Individual Sewage Disposal
..................... M........... ----------------._.._...._ ......................
I.ot No. J/�
Address
Type of Building Size Lot _____________________....... Sq. feet
Dwelling —No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other —Type of Building _______________ ---------- No. of persons...-_____-____ ----------- Showers ( ) — Cafeteria ( )
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. 1 ________________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--------------------------------------------------------------------------- --------------------------------------------------------------------------------------------
------------------------------------------------------------------------------ ---•-----••-•---------.....-----------------------------------...-----------------------------------...------------------
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�'- -�-------- ��j -,
Nature of Repairs or Alterations —Answer when applicable.______ 17_ --------------------
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Agreement :
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITTIE 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 f health.
Signed--- ------•---•----- 4 ,l.
Date
ApplicationApproved By ....................................................... ............. ............. -------------------------------------...............
Date
Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------
-----•----•--•------------------•--•-----------------•-------------------•----------......----------•--•- ----------- ----------------- ------------------------------------------------------------
Date
PermitNo --------------------------------------------------------- Issued.------ -----------------------------..--_.._-----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWIr'....... O F............YARMOUTH
........................ ............................
Tntifiratr of &-impliancr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X)
by---- -•--•-----------------•-------------------------------- ----------------------•-------------------------------•----•------------------------------•-•--•-------
Installer
at......... 1Q._INDIAN--- MIORIALAM.-...$., - --------------------------------------------- ....... ----------------------------------- --------------------------------
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, N0.__82-211_______________________ dated ---------- 4182-.-..___..._._..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT EE STRUE® AS A GUARAN THAT THE
SYSTEM WILL FUNCT40N SATISFACTORY.
�j-------------------------------- Inspec DATE ............. - �-•-2=�---- P -- --• - -- ----- -- - = ........------------.....