HomeMy WebLinkAboutApp-Permit-ComplianceA
YAKIVIUU I ri r7tHL 1 h UtFJ.
Tfth Office Building
No.._& .... .._.... South Yarmouth, MA, 02,66
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H LTH
.......... j1 ........... OF ......//� grew
14e� o1a
Appliratiaan for Hist sal Marks Tonstrudivit firrnti#
Application is.hereby made for a Per"}t to 7struct ( ) or Repair ( �a.n Individual Sewage Disposal
System at:., /Ji f ;%
Address
Type of Building
Dwelling —No. of Bedrooms .................................
Other — Type of Building ............................ No.
Other fixtures
a"
or ter............
"
........... Z ......... ..............
ie=Y ddr
Address "
Size Lot ............................ Sq. feet
........ Expansion Attic ( ) Garbage Grinder ( )
of persons ............................ Showers ( ) — Cafeteria ( )
..---- -•-•-•------•-. •-•..............•-•--...-----•---•-----•-----......-------
*
Design Flow............................................gallons per person per day. Total daily flow ............................................gallons.
Septic Tank — Liquid ' ca.pacity............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 ........................
Description of Soil..
...................••-•---.......------------•--•-------...---•--......-----------...-----------..........------------.................
......-•-•••-------•----...-••-----•--•--•-------••-----••-•-------•--•--•--•-•---------••-•••-- • -
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Nature of Re airs Altea�n s — Answer when applicat�e �/�L�_'_ ...._._% V f
........................................................1./_._. ...x.41
Agreement
The undersigned agrees to install the aforedescribed vidual Sewage Disposal System in accordance with
the provisions of TITU, 5 of the State Sanitary Code — u dersi ned rt ag not to place the system in
operation until a Certificate of Compliance has bee is ed a and of e
Sig ----
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--- ----- --...1.1.1.---------
_ to
Application Approved By- .1 1.11 . ---- ....-•--•-----••---------•---•.........._ 1... _.._...
--
Date
Application Disapproved for the following reasons--------------•------------------...----------------------------.....-•-•--•-•-•--------••-••-•---•--..........
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Permit No ........ 4:.._ l ----------------•---._...... Issued. /...--
Date
THE COMMONWEALTH OF MASSACHUSETTS
,,. BOARD OHEAL"P
1111..�d/L................OF..:. 1111 ........................................................
Trritf of Taaut haurr
THS I T�:c
Fi ,,: l t th Indikid ial Sewage Disposal System constructed or Repaired
P°�'�:'{. :,r..` 1111 �..)...... �. `
.:. ... -- ..._..
A - .� _J .I/ ��. Installer,/f .�
»..... -.....---:..... .......:........ ..-.z:. ........ .r-:... ........ -6:-- ..... _.r....-r._:...........-----...............................................................
has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Cod as e-cribed in the
application for Disposal Works Construction. Permit No....._.�e. __.�....__...... dated__.:__r....�L/
THE•ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS_A G A ANTEE THAT THE
SYSTEM WIL FUN " ION SATISFACTORY _ t
DATE. 1 1- ..--. ---- Inspector .. / A : rte; f ` -