HomeMy WebLinkAboutApp-Permit-Compliance• ►.•i...vv:1 .1 1 Filb nW u11f fioklF I.
85--s-0 Town Office RhAtding
xo.._.... .. South Yarmouth, ,MA 02.664 Fic$......!. .._....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......OF......r1lVorks
................................•---...................................
, ppliration fur Dispns Tonstrurtinn itermit
Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
....-•--•--•-•--•---- Z�-1 =S! M jgP..:...11 1 ........................
or Lot No.
type of nuumng
Dwelling —No. of Bedrooms............................................Expansion Attic
Other — Type of Building ............................ No. of persons .............._....
Other fixtures
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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Descriptionof Soil ........................................................................................................................................................................
--•....•----•--------•-----------------------•--...........-•-......------.....•-•-----••-.....----•----------•-----------------...•----•--•---...•-----......--•• •-•-•--•--•---•---•--------•--•---••--
••--•...•••---------------------------••••---------------------------------•-------------•---------------- ---- -- -- ----- ------
Nature of Repairs or Alterations — Answer when applicable_Z.iii i.. _- ._ ..._ .-_-•---J- � . -- .•_
... ----•----•-------•---------•--.....-----•----•-----------------•----•-------------•---•----•-•----•-.....-----------------
•. ...... ........
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITS � 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha been ' sued by the boa o ea h
Sign
7 f}tiS-'
to
Application Approved By ....... .-- .-•-- /O
Date
Application Disapproved for the f ollo ing reasons:-------•-------------•------....---•-------------------•--•--------.......--------...................---........
•-------------------------------------------------------------------------------------------------------•..----------------------------•-------------•-----......------•------- ..----•.-•-.
PermitDate
No......L .. S...................... Issued. ........... - .
0 S
Date .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,4
.....:'lrr(}.-%rte .......OF ....qKVt ..................................
(Entifirati jaf Tvutjdl attrr
THIS IS ,)O CER IFY, T t the Individual Sewage Diqposal System constructed
or Repaired
•• ---.. ..... ....
Mst 11er
has been installed in accordance with the provisions of TITLE_ r f tate SanitaryCo�el' rTr edin the
p `I' j� _ _..... dated ............... //J�
application for Disposal Works Construction ermit No ._.�. ,�
i -----------------• --•------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO�'SAWACTORY.
DATE ................ .%�4/ �� Inspector---- .................... i:1�4_�