HomeMy WebLinkAbout0155 OLD YARMOUTH ROAD - Health (3) ��.���� S
�.
'I
No.. � ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�0 .... ,5 /��.�4..G=-------- ................
- - .-......... OF.
Appli.ratiun for :45iupuuttl Worko Tomitrurtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
O Gel. f� P
Location-Address _ or Lot No. , YI�i�+v�s
'000
Owner Address
Installer Address
d Type of Building Size Lot•___________________________Sq. feet
U Dwellin —No. of Bedrooms��l1_�`f4lgXelh'G 1 Expansion Attic ( ) Garbage Grinder ( )
" ..... No. of persons............................ Showers — Cafeteria p., Other Type of Building . ___CL�� p ( ) ( )
a' Other. fixtures -------------------...................................
W Design Flow........... ....:...................gallons per person per day. Total daily flow..........l0-__�!-----------------------gallons.
WSeptic Tank—Liquid capacity__OQ-04kallons Length---------------- Width---------------- Diameter---------------- Depth--------- ......
x Disposal Trench—No............... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit Di ' etef.................... Depth below inlet.................... Total leaching area---. G_�sq. ft.
Z Other Distribution bok ) Dosing tank ( )
aPercolation Test Results Performed by----•----------••-_........--•-------•-------•-•--•...................•-- Date------••--------------------------------
a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water--------.-___-___------.
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-________-____-__-_--.
a' .................... ---------------------------•----------------•------------------------•-------•---------•------------..._......-------------
O Description of Soil---------------------jw_1&.
x
W
UNature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by th boar f boffth.
Signed_k. !_. __ .
Da,/
Application Approved By-•-•-•-•••••-----•-----•-••-•--••-...-•--------•-•••---•-••---------------•-----•••••-••••••----
----------------------------------------
Date
Application Disapproved for the following reasons:-------•--------------•----•---••--•-----•-•---•-•---•--------------••---•-•--------------•---------------------
........--•••-••••-------••----•---•-----••-•--••---------•----•----•---------••---••----•--••----•.......••-•-••-••-----•------------------------------•-•-----------------•-••------------••--•--•....
Date
PermitNo......................................................... Issued........................................................
Date
No.-'-f.. -------- FE>�. ..........5...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
_1{
, ppliratiuta for Dispoo l Workii Tomitratrtion tIrrmit
Application is hereby made for a Permit to Construct ( ) or.Repair ( ) an Individual Sewage Disposal
System at,:
>!
------------ --------------------------
l�-^ Location-Address ........................
-:e 8�, or Lot No . �/
�.4+ .............................. "`x� �• ^�'"'C
7 f 7i ' "`�f� yt'_i..` G ....................... ...--------._.. ' ----'-......-a-.._..---'---'
Owner Address
W
Installer Address
d Type of Building , Size Lot............................Sq. feet
Dwelling—No. of Bedrooms f'.�—�n':°r: 's....!._..-......Expansion Attic ( ) Garbage Grinder ( )
P-1-, Other?-Type of Building ......=':=' .� No. of persons____________________________ Showers ( ) — Cafeteria ( )
dOther fixtures --------------- ---- -7------------------_-------------------------------------------------------------------------------------------------------
W Design Flow........... __ ----___________________gallons per person per day. Total daily flow........... j%. ..._._........__._.._._gallons.
WSeptic Tank—Liquid capacity-_*_e.Pallons Length................ Width---------------- Diameter................ Depth__________..-.
x Disposal Trench—No............... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit D a eter____________________ Depth below inlet.................... Total leaching area---- ft.
Z 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------------------------
P4 ---------------------------------------------------------------------•------------------------------------•--•------•-----------------------------•-•----•--
D Description of Soil....................... 1.== �
-------------------------------------------------------------------------------------------------
x
U -------------'---------•'-'------------••••----'-'•-••-••••---•-•••---••-----------------------'---••--•••-•--------------------------------------------------------------------------------------------
W
----------------------------------------........................................................................................---------------------------------------------------- .................
U 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ipoed by
t boar_!df-
th
t
Signed ....-- +r- .I e - --"- --------- ------- -- -- -
Dat ._
ApplicationApproved By.................................................................................................. ----------------------------------------
Date
Application Disapproved for the following reasons:...............................•-----------------------------------------••---•--------------------------.-----
----------------------------•-------------------------------------------------•-•----------------•------•..
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Trrtifir atr of Toutp1tattarr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( )
.:. J1�
��> x
Installer
at ----- •_ .......... .................................i ----- -.
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......�;I-v-__"��'__________________ dated------------ ._ i.f__c'.. ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- --
.�.�..009 9--------------'•----•---------------•-------•--.. Inspector--------- -------•- ----•-•-• -•-------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ s... -1..... ......•
No..--- FEE.. '
�i�����t� r�rk.� (�a�at�tratrti�aa �rrzittt _..
s,
Permission`is hereby granted..... _ __: - ............................................................`
to Construct (jam. ) or Repair (• ) an Individual Sewage Disposal System
at No..------r:_ ` ......-..i2'/ j.r 1`.fsl_ := '- 1 _'::... --------------------•-------••- ---------
r 1 ------
Street
as shown on the application for Disposal Works Construction Permit No------------ r... Dated------------------------------------------
...................
:'Board of Health '
DATE................` = -- z.�----------------------------•---------•----
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS