HomeMy WebLinkAboutApp-Permit-Compliancet nn'jr1vv 1,1 1 l lLr►t.1 1-i UF_,f i .
Town Office Building
No...�J... ....... South Yarmouth, .MA, 02,664 F>c$.. 1 ..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........-.O F.. ..........................................
, ppliratiun for 11tupuu 1iYorks (nunstrurtiun rrntit
Application is hereby made for a Permit to Construct
syst. _...... W - .....
Locati Ades
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it-Ire=f �--•--•------ -- -- S'�_.L! :_..._ t..----•- ----•
Installer
) or Repair ( l.olfan Individual Sewage Disposal
L(:)T- (Z34- mp-P--Do
or Lot No.
Type of Building
Dwelling — No. of Bedrooms ............................................ Expansion Attic
Other — Type of Building ____________________________ No. of persons .......... _........
.
Otherfixtures--------•---•--------------------------•-•-•--------._._...-••---..--••-- ••--••--
Address
Address
Size Lot ............................ Sq. feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
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 ........................
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Description.of Soil ----------------------------------------------------•------------•---------•---------------------------•---•---------•------------------------._.._.....--
............................................................................................................................................ ...........................................................
-----------•------------------••---•-------••-••-•----••-•----------------•----•-----•-...._.. •. •.------••.......--•-- ......
Nature of Repairs or Alterations — Answer when applicable _.1+_�!�G
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 undersign further agrees not to place the system in
operation until a Certificate of Compliance has b issued by the boa - o hea th. n
Signed-.---- - -- ----------- ----- `7 -O� &
...-••--------•-- •--•••--------------
D It
Application Approved By ...... ....... ........................................ _ ... S
Date
Application Disapproved for the following reasons--------------------------------------------------------------------•------------._._...............-----........
-•------------------------------------------------------------------------------------------------------- -••---•-----••-•---•-•--...--•--•-••----•-•---•--•---••-----•-------•-•--------•-•----•--------
Permit No.......� 4s5
--.................................. Issued.---- 1 ........................
ate
- — THE COMMONWEALTH OF MASSACHUSETTS lei ' C% rIL,V
by
BOARD OF HEALTH
:...........OF.... ...- ..y .. r!.'N$'�(,..........................
(Irr ifir ` of Toutpliatta
f
THIS IShO CERTIFY, That the Itoividual Sewage Disposal System constructed
PIhG`-n Q o
) or Repaired
nIf-
...........% f s 1 Instal er f! 1
at - : , :1A, z'? I „c� � ...................................................... has been installed in accordance with the provisions of T,T fc) The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ---- dated-_ .___t_L�.�Q._____ .._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE TH THE
SYSTEM WILL FUINCTION SATISFACTORY.
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DATE .... ... /G . .... Inspector....f /