HomeMy WebLinkAboutApp-Permit-ComplianceYARMOUTH HEALTH' DEPT.
Town Of -ice Bukding
03
No --V.......... ..... South Yarmouth, MA 02,0664
THE COMMONWEALTH OF MASSACHUSETTS
BOARD��OF HE TH
77%i��V ....... OF ...... . .. ....... .. ...............................................................
Appliration for Dispaual i0orko Tonstrurtion "nutit
V
Application is hereby made for a Permit to Construct or Repair ( J,�an Individual Sewage Disposal
System at LOT 3 yy)
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- -!.T- V, ...............
L Cat n -Address or Lot No.
.......... ;;,,:;?;L ..... ....................... .... ... . ......... ..........
es
4
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Installer 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. 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._._._...._____.__..___.
Descriptionof Soil ------------------------------------------------------------------------------------------------
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------------------------------------ ------------------------------------------------- ---------- .......... ... A-0-
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Repairs
U N _pr Alterations —,5,�,swer when apj
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...............••-• ! .2 Zee/
...
Agreement:
The undersigned agrees to install the aforedescribed� dividual Sewage Disposal System in accordance with
the provisions of T I 'L LZ 5 of the State Sanitary Code , Y -e and ign fur ag7�1 not to place the system in
operation until a Certificate of Compliance has been i u h of.
Signed------ ..... . ......... -------- .... .. ... ..... ... ...................... ...... ....... .. ... -----•
D
Application Approved By .. .. .......................................... ............ ..0 .. ... ..........
Date
�
Application Disapproved for the following reasons: .............................................................................................................. -
.................................................................................................................................... ........................... ... -/ ....... Date ..............
Permit No ................................................... --- Issued.._.....--
............. .
Zate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD)0 HEA
............. ................... OF ....... 1XIe ......................................
&rfiffratr of
or Repaired (Pl'
THIS,J-S TO CEV�IT._ITA�Yy
,��hapt�h�eipduaJ Sewage Disposal System constructed ep
............
_ - �uer
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.... ............ ��. 0
by ------ - --- .. .... --- -'
/at 7 ------------------- -----
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has been installed in accordance with the pyov' ions 0 TITLE 5 of, The State Sanitary Code as described in the
application for Disposal Works Constructi , ermit No_____________________ ----------- -- dated._ ____.._.. __......_ ___....-.____.--..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
12 11 --) 1634 Inspector .... ...... L/I.A" .................................
DATE .............. L.,a ............................................................. r