HomeMy WebLinkAboutApp-Permit-ComplianceYAKIVIVU-1-,H' HEALTH DEPT$
Town Office Buildlingi
No.!?.M ..---.. South Yarmouth, h ,PSA 0,2554 FEs....J�...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F......................................----------.....................------...............
Appliration for Disposal Works Toustrurtiun Jrrmit
Application is hereby made for a Permit to Construct
System at:
---...._.........:....-----...............................
atio- n _Add;ess
...
caner
.................................. - - ,... -•---- ...........•......
Installer
Type of Building
Dwelling — No
Other — Type
) or Repair (,L-) an Individual Sewage Disposal
z_oT-
�xso ,t4f /�iFbj.P �-�
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_.....�...._
.............
Address
I Address
Size Lot ............................ Sq. feet
of Bedrooms.................`.L
.................... Expansion Attic ( ) Garbage Grinder ( )
of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----------------•-.................................--.---•--------------.......---•-•------------•---•-----------•-................----•-------------
Design Flow................E5 ..................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................minutesper inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil ....................................
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Nature of Repairs or Alterations—Answer when applicable-.A(?1?.." __ Zi ! ! ..__ ! _._ ..2..":4i��':_ ..dt..."
_ u?Q Fec15 Q.. .... gym... J�Jlm$.....umom•---------------------------------------------------------------------------------------------------
Agreement :
The undersigned agrees to install jaforribed Individual e e Disposal System in accordance with
the provisions of ITL:, 5 of the State —The under i d fur er agrees not to place the system in
operation until a Certificate of Compliancued the f heal/ /Si ............ •7f .��.............
Application Approved BY �`v -- ......• t -------•-- .......
Application Disapproved for the f oll ing reason/s: ......... ------- -------•-----------------•--•-----•---.....-•---•-•-•--..............
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IC
PermitNo. .f 9�--------•........................._....
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/_.....Date -._...
Date
THE COMMONWEALTH OF MASSACHUSETTS`'
br7ep5 Is
BOARD OF HEALTH
O........ I ................................. OF........................... .........................
Trrtifiratr of f omplinnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed
by
has been installed in accordance with the provisions o
application for Disposal Works Construction Permit N
THE ISSUANCE OF THIS CERTIFICATE SH
SYSTEIrA)NILLL TI SATISFACTORY.
DATE���''=��-------------- _ =
Installer
) or Repaired ( )
.. _.1
f .. � of The State Sanitary ode, f (tslo in the
o.. -------- -------------- da ed
ALL NOT BE CONSTRUED A� iJ/k"NTEE THAT THE
Inspects...-�.. ;t.